REPUBLIC OF THE PHILIPPINES )

CITY OF TAGUM ) S.S.

PROVINCE OF DAVAO DEL NORTE )
x----------------------------------------------------x

AFFIDAVIT OF LOSS

I, ANGEL QUILLA BANGCASAN, of legal age, Filipino and a resident of Purok 1B,
Kumintang, Maniki, Kapalong, Davao del Norte, Philippines, after having been sworn to in
accordance with law do hereby depose and say:

1. That I am the holder of Globe Sim Card No. 09274770663 issued by Globe
Telecommunications Company in Tagum City, Davao del Norte;

2. That I inserted the said sim Card to my mobile phone;

3. That sometime on _______________, while strolling around ________________

I discovered that my mobile phone, where the Sim Card was inserted, was no
longer in my pocket;

4. That the Mobile Phone and the Globe Sim Card could no longer be found despite
the diligent efforts I exerted to locate and/or find the same. Thus, I consider the
said Globe Sim Card to have been lost forever without expecting its recovery;
and

5. That I am executing this Affidavit to apprise authorities concerned of the

foregoing facts and for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have signed this on April 20, 2023 at Tagum City, Davao del
Norte, Philippines.

ANGEL QUILLA BANGCASAN

Affiant
Valid I.D: PHIC ID No. 16-050639575-2

SUBSCRIBED AND SWORN TO BEFORE ME, this April 20, 2023 in Tagum City,
Davao del Norte, Philippines. Affiant exhibited to me her valid I.D. indicated below her name.

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