REPUBLIC OF THE PHILIPPINES)

_____________________________ ) S.S.

AFFIDAVIT OF LOSS

I, _____________________, Filipino, of legal age, residing

________________________________, after having been sworn in accordance with
law hereby depose and state:

That I am the true and lawful owner of a certain mobile

phone which is more particularly described as follows:

MAKE : ______
SERIES : ______
COLOR : ______
MOBILE NOS. : ______________________________

That on ____________, while riding a public utility vehicle

going to work, somebody pickpocketed my phone;

That I tried to located and contact my phone, but to no avail;

That the above mobile numbers are both very important to

me, being my business phone number and personal phone number;

That I am executing this affidavit to attest to the truth of the

foregoing and to request replacement of my stolen prepaid sim
cards.

IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of

_______________. 20___ at _________________________.

_______________________
Affiant

SUBSCRIBED AND SWORN TO before me on _______________________ in

__________________, affiant exhibiting to me his ID No. _____________________.

NOTARY PUBLIC

Doc. No. : ________;

Page No. : ________;
Book No. : ________;
Series of 20_______.