REPUBLIC OF THE PHILIPPINES)

City of Lucena ) S. S.

AFFIDAVIT OF LOSS

I, RAMON C. SALDIVIA, of legal age, Filipino, married, and a resident of

Barangay Potol, Tayabas City after having been sworn to in accordance with law,
do hereby depose and state that:

1. I am the holder of a pawn receipt issued by Raquel Pawnshop ll,

Lucban, Quezon;

2. The aforesaid pawn receipt was lost last March 2018 as it was
misplaced at above given address;

3. Earnest effort has been exerted by me to find the said pawn receipt
but to no avail; and

4. I am executing this affidavit to attest to the truth of the foregoing and

for whatever legal purpose it may serve.

Affiant sayeth naught.

Lucena City, 27 April 2018.

RAMON C. SALDIVIA
Affiant

SUBSCRIBED and SWORN to before me this 27th day of April 2018 at

Lucena City, affiant Ramon C. Sadivia appeared in person, was identified by me
through competent evidence of identity by exhibiting to me his ID No. 5647-
0183A-L0876RCS100000, bearing his photograph and signature issued by the
Commission on Elections, Tayabas City, and signed the said Affidavit of Loss in
my presence.