REPUBLIC OF THE PHILIPPINES)

BAUAN, BATANGAS ) S. S.

AFFIDAVIT OF LOSS

I, LELANY SEGURA GABAIS, married, of legal age, Filipino Citizen and a

resident of #23 Gen. Luna St. Bolo, Bauan, Batangas, on oath, depose and say:

Pawnshop: SINAG PAWNSHOP CORPORATION

Branch: Bauan Batangas
Pawner: Lelany Segura Gabais
Address: 229 Cotabato St. Sapa II Rosario Cavite
Contact No. 09173520471
Pawnticket No/s.: 113
Loans Granted Date: July 24, 2022
Expiry Date: August 23, 2022
Description/s: Two (2) Chain, One (1) Bracelet (ID), One (1) Heart
Pendant
Karat: 925
Gram/s: 71.36
Principal Amount: Php 1,400

That sometime on August 2022, I found out that the pawnticket were lost.

That I exerted diligent efforts to locate the same, but I failed to find it;

That it probably has been lost and the same are beyond recovery;

That I am executing this affidavit for the purpose of affirming the foregoing
facts and so that I may use this for all legal purposes and intent.

IN WITNESS WHEREOF, I signed this affidavit this _________________ at

Bauan, Batangas.

LELANY SEGURA GABAIS

Affiant
CRN-0002-2007103-9

SUBSCRIBED AND SWORN TO before me this ____________________ at

Bauan, Batangas, affiant exhibiting to me her valid proof of identification as described
above.

Doc. No. ___ ;

Page No. ___ ;
Book No. ___ ;
Series of 2022.