REPUBLIC OF THE PHILIPPINES )

PROVINCE OF __________ ) S.S

CITY OF _________________ )

AFFIDAVIT OF LOSS

I, ABCD E. DELA CRUZ, of legal age, single, Filipino citizen, married under the
Philippine laws, and a resident of ______________, after having been duly sworn to in
accordance with law depose and state under oath that:

1. I am the holder and subscriber of a sim card bearing number ______________, duly
issued by the Globe Telecommunications, Inc.;

2. The above-mentioned sim cards with the said digits have been inserted in my cellular
phone. The same digits have been active since the time of issuance of the same. I also
registered the same number to GCash app. The last time I used the above-mentioned
digits, an amount of Php1,500.00 has been deposited or cashed therein;

3. Unfortunately, I discovered that the sim card is no longer in the pouch where I kept it
following the removal of the same when I needed to insert a Smart sim card;

4. Immediately, upon discovery of the fact of loss of the said sim card, I searched
thoroughly in places where I might have transferred it. Adding to my dismay, the same
turned futile as I was not able to recover or find the said phone;

5. Despite diligent search and efforts for the sim card bearing number
_________________ to be located and restored, the same could no longer be found,
hence lost beyond recovery.

6. I am freely and voluntarily executing this affidavit to attest to the veracity and
truthfulness of fact of loss of the sim card bearing number ________________;

7. I am further executing this affidavit purposely to secure and retain the same sim card
and to claim back the available Gcash balance in the same sim card, upon application
with the Globe Telecommunication, Inc. and payment of applicable fees and for
whatever legal intents and purposes it may serve.

Affiant further sayeth naught.

IN WITNESS WHEREOF, I have hereunto set my hand this 19 th day of May, 2021,
in ________________________.

ABCD E. DELA CRUZ

Affiant

SUBSCRIBED AND SWORN to before me this 19th day of May, 2021, in

___________________. Affiant personally appeared and exhibited to me his Identification
card bearing No. ______________, valid until ________________, duly issued by
___________________, as competent proof of his identity.

Doc. No. : ____;

Page No. : ____;
Book No.: _____;
Series of 2021.