REPUBLIC OF THE PHILIPPINES )

Lingayen, Pangasinan ) S.S.

AFFIDAVIT OF LOSS

That I, GERONIMO Q. DE GUZMAN, of legal age, married, Filipino citizen, and a

resident of ALVEAR EAST , Lingayen, Pangasinan do hereby states that:

1. That I was issued a OFFICIAL RECEIPT from Cebuana Lhuillier ;

2. However, due to inadvertence, the said Certificate got misplaced and eventually
got lost;

3. I had exerted effort to look for it but still, I could not find it;

4. That I am executing this affidavit to attest to the veracity of the above-stated

facts, for the purpose whatever legal purpose which this affidavit may serve.

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

in________________________.

GERONIMO Q. DE GUZMAN
Affiant

SUBSCRIBED AND SWORN to before me, this ____ day of _________________ in

___________________, with affiant exhibiting her Senior Citizen I.D. No. 20619.

Doc. No. : ________;

Page No. : ________;
Book No. : ________;
Series of 2019.