REPUBLIC OF THE PHILIPPINES)

MALOLOS CITY, BULACAN ) S.S.

AFFIDAVIT OF LOSS

I, VIRGINIA B. CABICO, of legal age, widow, Filipino, and

presently residing at #1 Dizon Compund, G. Marcelo Street, Maysan,
Valenzuela City, after being duly sworn do hereby depose and state, that:

1. I am a holder of a Pawn Ticket with Ticket No. 20110SG037131

issued by the Cebuana Lhuiller;

2. On December 8, 2019, while cleaning our house in #1 Dizon

Compund, G. Marcelo Street, Maysan, Valenzuela City, I checked
my documents inside my bag and I noticed that the afore-
mentioned Pawn Ticket was missing;

3. The said ticket was accidentally misplaced somewhere in our

house and nowhere to be found;

4. I exerted diligent effort to locate the said Pawn Ticket but all my
efforts are in vain; and

5. I executed this affidavit to attest to the truth of the foregoing set of

facts and to inform the authorities concern for all legal intents and
purposes.

Malolos City, Bulacan December 9, 2019.

VIRGINIA B. CABICO
AFFIANT

SUBSCRIBED AND SWORN TO BEFORE ME this 9th day of

December 2019 at Malolos City, Bulacan. Affiant exhibited to me her SSS
I.D. with No. 03-5379484-3.

Doc. No. 136;

Page No. 29;
Book No. XIV;
Series of 2019.