REPUBLIC OF THE PHILIPPINES)

C I T Y O F I L O I L O )Sc.
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AFFIDAVIT OF LOSS

I MERCY LINA V. DOMINGO of legal age, Filipino, and a resident of Oton,

Poblacion,Iloilo after having been duly sworn to in accordance with law, hereby depose and state
THAT:

1. On July 12, 2019 I pawned my Pulcera 9.7 grams 18k with the Cebuana Lhuillier
, Oton Branch and for which I was issued a Pawn Ticket/Receipt No:
60185SG031944;

2. I kept the said pawn ticket in my wallet for safekeeping but unfortunately my
wallet got lost;

3. Despite diligent search and efforts to locate the same wallet and pawn ticket, I
could not find the same and I conclude that both the said wallet and pawn ticket
are now lost and beyond recovery;

4. As such I am executing this affidavit to attest to the truth of the foregoing facts
and to enable me to secure a duplicate or substitute copy of the said pawn ticket
and to redeem the above described item which I pawned.

IN WITNESS WHEREOF, I have hereunto set my hand this ___________________ in

____________, Philippines.

MERCY LINA V. DOMINGO

Affiant
PAG-IBIG ID No.: 1210-7521-9738

SUBCRIBED AND SWORN TO before me this ___________________ in Iloilo

City, Philippines, affiant exhibiting to me her valid proof of identification written above.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2019.