REPUBLIC OF THE PHILIPPINES)

CITY OF GENERAL SANTOS…….) S.S.

X-----------------------------------X

AFFIDAVIT OF LOSS

I, JAY-AR DELOS SANTOS ANTONIO, Filipino, of legal age, and a resident of

Prk.1 Brgy. Mabuhay, General Santos City, after being duly sworn to in accordance with law,
hereby depose and say:

1. That I pawned one (1) yg necklace -box- w/ heart pendant approx. 2.0g/18k
with Palawan Pawnshop located at Mabuhay, General Santos City, with the
following details:
PAWN TICKET NO. : #22597
RENWD FR PT : 22261
LOAN DATE : August 22, 2022
MATURITY DATE : September 21, 2022
EXPIRY DATE : December 20, 2022
PRINCIPAL : PHP 5,000.00
DESCRIPTION : BRACELET 2.5G, 18K, SIZE 7.5

2. That I had the said pawn ticket placed inside my wallet for safe-keeping and
future reference;
3. Lately, I tried to retrieve the above-mentioned pawn ticket; however, I
discovered that the same was already lost and could no longer be found;
4. That despite diligent efforts to locate and find said pawn ticket, the same could
no longer be found and is now beyond recovery;
5. That I execute this affidavit to attest to the truth of the foregoing for all legal
purposes.

IN WITNESS WHEREOF, I have hereunto set my hand this November 7, 2022, in

General Santos City, Philippines.

______________________________________
JAY-AR DELOS SANTOS ANTONIO
Affiant

SUBSCRIBED AND SWORN TO before me this November 7, 2022, in General

Santos City by affiant who exhibited to me his valid ID No.:_______________.

DOC. NO. 222 ;

PAGE NO. 45 ;
BOOK NO. 195 ;
SERIES OF 2022.