Republic of the Philippines
City/Province of
S.S.

I, , of legal age, Filipino, residing at , after having been duly sworn in accordance with law, do hereby depose and state:

1. That I am the lawful owner/user of the prepaid SIM card with the following details:
   
   Mobile Number
   SIM Card Serial Number
   Network Provider
2. That on or about , said prepaid SIM card was lost due to .
3. That efforts to locate or retrieve the lost SIM card have been made, but to no avail.
4. That I am executing this Affidavit to attest to the truth of the foregoing facts and to comply with requirements for replacement of my lost prepaid SIM card.
5. That I am willing to be held liable for any misrepresentation or false statement in this affidavit.

IN WITNESS WHEREOF, I have hereunto set my hand this day of , 20 at , Philippines.

ACKNOWLEDGEMENT

SUBSCRIBED AND SWORN to before me this at , affiant exhibiting to me his/her with number issued at on .