REPUBLIC OF THE PHILIPPINES )

PROVINCE OF PAMPANGA ) S.S.

AFFIDAVIT OF LOSS

I, , of legal age, Filipino Citizen, with residence at Brgy. Balantacan, Lubao,

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

1.) That I was issued a PAWN TICKET by CEBUANA LHUILLIER

PAWNSHOP LUBAO BRANCH situated at Sta. Cruz Lubao, Pampanga because
I pawned my wedding ring;

2.) That on , I was cleaning my room inside my house when I suddenly

discovered that the pawn ticket placed at the drawer of my desk for safekeeping
was missing. That in all probability said pawn ticket was commingled with the
other receipts and documents that I threw to the garbage container;
3). That in all likelihood the PAWN TICKET issued in my favor by
CEBUANA LHUILLIER PAWNSHOP was accidentally included along with
the receipts and documents that were thrown to the garbage container;
4). Further, I extensively search the four corners of my house but I failed to
find it; and

5). That this affidavit is executed to attest to the truth of foregoing facts and
for the sole purpose of informing the CEBUANA LHUILLIER PAWNSHOP
regarding the loss of my PAWN TICKET and respectfully request to issue a new
one.

IN WITNESS WHEREOF, I have signed on this 16th day of June, 2021 at

Lubao, Pampanga.

Affiant
SUBSCRIBED AND SWORN to before me on this 16th day of January,
2021 at Lubao, Pampanga. Affiant exhibited to me his Competent Identification
Document as stated below his name.

Doc No.
Page No.
Book No.
Series of 2021.