REPUBLIC OF THE PHILIPPINES..

…)
PROVINCE OF NEGROS ORIENTAL) S.S.
CITY OF DUMAGUETE…… …………)

AFFIDAVIT OF LOSS

I, KC, of legal age, Filipino, married, with residence and postal address at B10 L11
_____________, Negros Oriental, Philippines, under oath, hereby state:

1. That on November 24, 2018, I pawned to Cebuana Lhuillier one (1) pair earring
18k, 2.3grams for P2,270.00 and was issued pawn ticket no. ____________ and;

2. That on November 24, 2018, I pawned to Cebuana Lhuillier one (1) pair of
earring 14k, 2.8grams for P2,005.00 and was issued pawn ticket no. _____________;

3. That I lost tracked of the whereabouts of the aforesaid Cebuana Lhuillier pawn
ticket;

4. That I exerted diligent efforts to locate the said Cebuana Lhuillier pawn ticket
with pawn ticket no. ___________ and ______________, but the same proved to be fruitless,
and I now treat the Cebuana Lhuillier pawn ticket to be lost beyond recovery;

5. That I am executing this affidavit to establish the fact of its loss and to support my
claim with Cebuana Lhuillier with pawn ticket no. ___________ and ___________ to redeem
the aforesaid pawned item and for whatever legal purpose this may serve best.

IN WITNESS WHEREOF, I hereunto set my hand this 19th day of December 2018 in
Dumaguete City, Negros Oriental, Philippines.

kc
Affiant

SUBSCRIBED AND SWORN to before me this 19th day of December 2018 in

Dumaguete City, Negros Oriental, Philippines.

 
Doc. No. __;
Page No. __;
Book No. __;
Series of 2018.