REPUBLIC OF THE PHILIPPINES)

PROVINCE OF NUEVA VIZCAYA) S.S.

MUNICIPALITY OF BAYOMBONG)

AFFIDAVIT OF LOSS

I, THELMA V. TOLENTINO, of legal age, married, Filipino

citizen, and a resident of Bonfal Proper, Bayombong, Nueva Vizcaya, after
having been duly sworn to in accordance with law hereby depose and state:

1. That I am a bonafide holder of a Samsung cellphone with Sim Card

Number 09175139090 issued by the Globe Telecom, Solano Branch,
, Nueva Vizcaya;

2. That the aforesaid cellphone with globe sim card was always in my
possession. However it was lost sometime in June 26, 2017 , and
despite earnest efforts to locate it, I failed to find it anymore;

3. That finding the futility of recovering the said cellphone and its sim
card , hereby declared that the same are considered lost and beyond
recovery;

4. That I attest to the veracity of the foregoing statements and hereby

execute this affidavit for the purpose of securing another in lieu of the
lost one.

IN WITNESS WHEREOF, I have hereunto set my hand on this

affidavit this 3rd day of July 2017 at Bayombong, Nueva Vizcaya.

THELMA V. TOLENTINO
Affiant
Pag-Ibig Loyalty No. 1210-8760-8829

SUBSCRIBED AND SWORN TO before me this 3rd day of July 2017

at Bayombong, Nueva Vizcaya.