Republic of the Philippines )

Province of Palawan )S.S.

City of Puerto Princesa )

AFFIDAVIT OF LOSS

I, ___________________, of legal age, Filipino, single and a resident

of _______________________________, after having been duly sworn to
in accordance with law, depose and state THAT:

1. Sometime on ______________, I pawned my _________ with

Tambunting Pawnshop located at _____________________ and for which I
was issued Pawn Ticket/Receipt No. _________;

2. I kept the said pawn ticket in my wallet for safekeeping but unfortunately
my wallet got lost;

3. Despite diligent search and efforts to locate the said wallet and pawn
ticket, I could not find the same such that I believe that they are now lost
beyond recovery;

4. As such, I am executing this affidavit to attest to the foregoing facts and

to enable me to secure a duplicate or substitute copy of the ticket and/or
redeem the above-described item which I pawned.

IN WITNESS WHEREOF, I have hereunto set my hand this 29th day of July
2022 in Puerto Princesa City, Palawan, Philippines.

LUCIA L. TAN
Affiant
Voter's ID No. 5555

SUBCRIBED AND SWORN TO before me this 29th day of July 2023 in Puerto
Princesa City, Palawan, Philippines, affiant exhibiting to me his valid proof of
identification.

Doc. No. _____;

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