Republic of the Philippines)

City of Butuan ) S.S.

AFFIDAVIT OF LOSS

I, MIGUEL L. CULASTE JR., of legal age, Filipino, and a resident of

Barangay Talisay, Nasipit, Agusan Del Norte, under oath, depose and state THAT:

1. I have pawned my necklace with a pdt of 6.5 grams with Cebuana

Lhullier Pawnshop, Nasipit Branch for and in consideration of the
sum of Eleven Thousand Five Hundred pesos (PhP 11, 500) and
as evidence thereof, said Pawnshop issued to me Ticket/Receipt
No. 60576SG015185, dated July 04, 2022;

2. Recently, I discovered that the said receipt was lost and can no
longer be found despite diligent efforts to locate the same;

3. I am executing this affidavit to attest to the veracity of the

foregoing and for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 19 th

day of August 2022 at Butuan City, Philippines.

MIGUEL L. CULASTE JR.

Affiant
Philhealth ID: 18-200501239-3

SUBSCRIBED AND SWORN TO BEFORE ME this 19th day of August

2022 at Butuan City, Philippines.

Doc. No. ________;

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