AFFIDAVIT OF LOSS

REPUBLIC OF THE PHILIPPINES )

MAKATI CITY ) SS.,

I, EMMANUELLE R. CONCHE, Filipino, of legal age, and a resident of Pabahay 2000

BLACK 13 Lot 6 Sec 23 Ph3 Bulacan after having been duly sworn in accordance with
law, hereby depose and say:
1. That I am a holder of the G-CASH card with account number 09957327512;
2. That I used to put said G-CASH card in my wallet;
3. That sometime on November 26, 2018 , when I arrived home from work, I discovered
that my card was no longer in my wallet where I used to place it;
4. That diligent effort to locate the same had proved futile;
5. That I am executing this affidavit to attest to the truth of the foregoing facts and to
request for a replacement of my G- Cash Card.

IN WITNESS WHEREOF,
I have hereunto affixed my signature this ____ day of November, 2018 at Makati City,
Philippines

____________________
(Signature of Affiant over Printed Name)

SUBSCRIBED AND SWORN TO

Before me, a notary public in and for _____________________ this ____ day of
____________ 20___. The affiant, whom I identified through the following competent
evidence of identity: Phil.no. 21-25626847-5, issued by Phil health Office, personally
signed the foregoing instrument before me and avowed under penalty of law to the whole
truth of the contents of said instrument.

Notary Public

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