Republic of the Philippines )

Mandaluyong City ) S.S.

AFFIDAVIT OF LOSS

I,________________, of legal age, legally single, Filipino with resident

address___________________________, after having been duly sworn in accordance with
law, do hereby depose and state that:

I pawned my One (1) Gold Necklace with Pendant at Cebuana Lhuillier

Pawnshop - Gen. Trias Cavite with following description:

NAME : _____________________
PT# : 0000000000000000000
DESCRIPTION : NECKLACE WITH PENDANT
18K / 1.82grams
LOAN DATE : 09-08-2023
MATURITY DATE : 10-09-2023
EXPIRY DATE : 01-08-2024
AMOUNT : Php 5,232.50

On 04th of October 2023, when I was about to claim the aforesaiod necklace, I
notice that the pawn ticket was missing;

I tried to search and locate the same but to no avail and believe is now lost and is
now beyond recovery.

I am executing this Affidavit to attest to the truth of the foregoing and to enable
to secure a duplicate or substitute copy of the ticket and/or redeem the above-described
necklace which I pawned and for whatever legal this may serve.

AFFIANT SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto set my hands this 09th day of

October 2023 at ______________City.

_______________________________________
Affiant

Signed in the presence of:

______________________________ _____________________________

SUBSCRIBED AND SWORN to before me in the City/ Municipality of

___________________ City, who has satisfactorily presented to me her competent
identification of Philhealth: ________________, that she is the same person who
personally signed before me the foregoing affidavit and acknowledge that she executed
the same.

Doc. No . ___;
Page No. ___;
Book No. ____;
Series of 2023.