Republic of the Philippines)

___________________________
X----------------------------------X

AFFIDAVIT OF LOSS

I, ______________________, of legal age, married, Filipino citizen, and a resident of

_________________________--, Philippines, after having been duly sworn to in accordance
with law, hereby depose and say that:

1. I am the owner of a certain jewelry pawned at CEBUANA LHUILLIER,

_________________________, more particularly described as follows:

Other Gold Coins 21k 31.92g

Amount: P50, 000.00
Receipt No. : -1234567

Other Gold Coins 21k 31.94g

Amount: P50, 000.00
Receipt No. : 8909867

2. However, due to inadvertence and/or oversight, I discovered that the original receipts of
said pawned jewelry were no longer in my possession and its whereabouts are nowhere to
be found.
3. I exerted diligent efforts to locate for the same in other places but all such endeavors
proved futile and to no avail;
4. For all intents and purposes, I am now declaring the original receipts of the pawned
jewelry lost and beyond recovery;
5. I execute this Affidavit to attest to the truth of the foregoing facts based on my personal
knowledge and authentic records in compliance with requirement of CEBUANA
LHUILLIER for the issuance of a new pawn receipts and for whatever legal purpose it
may serve.

IN WITNESS WHEREOF, we have hereunto set my hand on this 28 th day of April 2021
at __________________________, Philippines.