REPUBLIC OF THE PHILIPPINES )

DASMARIÑAS CITY, CAVITE ) S.S.

AFFIDAVIT OF LOSS
I, TERESITA S. TAPIADOR, of legal age, Filipino Citizen, and with postal and
residence address at Block 90 Lot 12 Brgy. San Juan, Dasmarinas City, Cavite, after having been
duly sworn to in accordance with law, hereby depose and say:

That I am the owner/holder of Pawn Ticket with No. 14196 issued by SMJ Pawnshop –
St. Peter Branch, for One (21 g necklace w/ pendant 18K – 4.8 KG) amounting to FIVE
THOUSNAD PESOS ONLY (Php5,000.00) with loan date on November 16, 2023;

That the said pawn ticket was misplaced/ lost;

That despite of diligent efforts, the said pawn ticket cannot be found and considered as
lost;

That I am executing this affidavit to attest to the truth of the foregoing facts for all legal
intents and purposes.

IN WITNESS WHEREOF, I have hereunto set my hand this 18th day of December 2023
at Dasmarinas City, Cavite, Philippines.

TERESITA S. TAPIADOR
Affiant

SUBSCRIBED and SWORN to before me on the date and place above-written, affiant
exhibiting to me his/her OSCA No. 10834.

Doc. No. 180

Page No. 35
Book No. 23
Series of 2023