REPUBLIC OF THE PHILIPPINES)

Province of Negros Oriental) S.S.

Municipality of Sibulan) 

AFFIDAVIT OF LOSS

I, FLORIBELL F. DUMAO, Filipino, of legal age and with postal address at Magatas,
Sibulan, Negros Oriental, Philippines after having been sworn in accordance with law hereby
depose and state:

That sometime on Ferbruary 4, 2023, at around 8:00 P.M while I was busy in our stall in
Negros Mecado located in Magatas Sibluan, Negros Oriental, I placed my Cellphone
(SAMSUNG A32) with Sim Card No. 09676937374, in my stall compartment;

That when I came back in my stall, I noticed that the said Cellphone (SAMSUNG A32)
with Sim Card No. 09676937374 was not anymore in my stall compartment and believed to be
stolen;

That said Cellphone (SAMSUNG A32) with Sim Card No. 09676937374 was registered
in the following mobile wallet(s) apps:

1. Gcash 2. Shopee 3. BPI bank

That I have reported the said incident to the Police Station of Sibulan, Negros Oriental and I
have exerted all efforts to locate the aforementioned Cellphone (SAMSUNG A32) with Sim
Card No. 09676937374, but despite diligent efforts exerted to locate them, the same can no
longer be found;

That this affidavit is executed freely and voluntarily just to attest the truthfulness and
veracity of the statements alleged herein to request for a replacement of my Globe Sim Card No.
09676937374.

IN WITNESS WHEREOF, I have hereunto set my hand this ________________ at

Sibulan, Negros Oriental, Philippines.
                              
FLORIBELL F. DUMAO
Affiant
ID: Driver’s License No. G02-23-000538

SUBSCRIBED AND SWORN to before me, a Notary Public, on_____________, for

the Municipality of Sibulan and the Province of Negros Oriental, Philippines, the above-named
affiant, who is personally known to me, and WHO SIGNED IN MY PRESENCE the foregoing
document (Affidavit of Loss), and who avows under PENALTY OF LAW to the whole truth of
the contents of the same.

Doc. No. ___;

Page No. ___;
Book No.___;
Series of 2023.