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Form No.1--Affidavit of Loss Cell phone SIM Card

(Affidavit of Loss Cellphone SIM Card)

Republic of the Philippines)
Province of_________________) S.S.
City/Municipality of____________)
x - - - - - - - - - - - - x


I,____________, Filipino, of legal age and a resident of ____________, Philippines, after being duly sworn in accordance with law, depose and state:

That I am a regular subscriber / user of a (Smart / Globe / Sun)Mobile SIM Card with No._____________;

That in the afternoon of _____________, I forgot my (O2 / Sony-Ericsson / Motorola / Samsung) cellular phone with the said SIM Card in it inside my car which I have parked along ____________;

That when I returned to my car at around________, I discovered that my cellular phone was missing together with my said Mobile SIM Card which was inside the said cellular phone;

That despite diligent search and efforts to locate said cellular phone, I could not find the same such that I now believe that said is now lost beyond recovery together with the aforesaid SIM Card;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing and in support of my request / application for the replacement of the said SIM Card.

IN WITNESS WHEREOF,I have hereunto set my hand this____________at____________, Philippines.





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