REPUBLIC OF THE PHILIPPINES)

CITY OF CEBU )S.S.

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AFFIDAVIT OF LOSS

I, JUVY GUMAPON, of legal age, married, Filipino, and residing in of

Barangay Hagdan, Oslob, Cebu, after having been duly sworn to in accordance, do
hereby depose and say:

That I am the owner of the jewelry item briefly described as “Lady Ring
Yupi/Deform”, 21K, 2.8grams” which I pawned in favor of Cebu Lhuillier
Pawnshop, Oslob Branch, Poblacion, Oslob, Cebu, in the amount of seven
thousand nine hundred eighty (P 7,980) on October 15, 2022;

That, as proof thereof, I was issued with a pawn receipt number

60792NP000300 to be used in redeeming the said jewelry item;

That the said pawn ticket, however, was lost in my possession and that
despite of earnest efforts to locate for the same, my efforts only prove futile and to
no avail;

That I could attest the fact that I have not sold or encumbered the said pawn
ticket to any person for any amount or value;

That, henceforth, I am executing this affidavit to declare the loss of the said pawn
ticket;

IN WITNESS WHEREOF, I have hereunto affixed my signature this 23 RD

day of November 2022, in the City of Cebu, Philippines.

JUVY L. GUMAPON
Affiant

SUBSCRIBED AND SWORN TO before me this 23 RD day of November

2022 in the City of Cebu, Philippines, after affiant exhibited to me her PAG-IBID
MID no. 1210-9813-8506, as competent proof of her identity.

Doc. No. _____

Page No. _____
Book No. ____
Series of 2022