REPUBLIC OF THE PHILIPPINES )

MUNTINLUPA CITY )S.S.

AFFIDAVIT OF LOSS

I, JOHN DOE, of legal age, Spanish, married and with residence

and postal address at _____________________________, after having been
duly sworn in accordance with law, hereby depose and state that:

1. On or about 24 September 2016 at around 12 oclock midnight,

I was at Molito Commercial Complex located in Madrigal Ave
corner Commerce Avenue, Alabang, Muntinlupa and used my
cellular phone with the Smart mobile number
______________________ to send a text message to a friend. After
which, I placed it inside the pocket of my pants;

2. About an hour later, I went home to my residence address and

discovered that my cellular phone is not inside my pocket where
I placed it last;

3. I looked for my cellular phone immediately after making such

discovery and spent the weekend of 24-25 of September 2016
trying to locate such cellular phone in the hope that it may be
found somewhere in my belongings;

4. Despite diligent efforts to search for the cellular phone, I could

not locate the same;

5. Hence, the cellular phone along with my Smart SIM card for
mobile number _________________________ must now be
considered lost; and

6. I am executing this Affidavit for all legal intents and purposes.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

26 September 2016 at Muntinlupa City.

JOHN DOE
Affiant

SUBSCRIBED AND SWORN TO before me this

______________________ at Muntinlupa City, affiant exhibited to me his
_________________________ valid until _______________.

Doc. No. ___;

Page No. ___;
Book No. ___;
Series of 2016.