REPUBLIC OF THE PHILIPPINES)

CITY OF PUERTO PRINCESA

) S.S.

AFFIDAVIT OF LOSS
That I, ANDY GALLARDO COYOCA, of legal age, married, Filipino and a resident of
Barangay Mandaragat, Puerto Princesa City, Palawan, Philippines, after having been duly sworn
to in accordance with law, hereby depose and say:
1.

That I am the holder of Pawn Ticket No. PT25783 issued by the Palawan Pawnshop
Junction II Branch covering the following items:
ONE PAIR YG EARRINGS APPROX. 1.0G

2.

Unfortunately, the above described pawn ticket got lost and all diligent efforts to locate it
proved futile. Hence, I declare the said pawn ticket as lost and beyong recovery.

3.

I am voluntarily executing this affidavit to attest to the correctness of all the facts stated
above and for whatever lawful purpose it may serve.

IN WITNESS WHEREOF, I hereunto affix my signature this 4th day of August 2015 at
Puerto Princesa City, Philippines.

ANDY G. COYOCA
Affiant
DL NO. D11-15-S08579
SUBSCRIBED AND SWORN to before me this 4th day of August 2015 at Puerto
Princesa City, Affiant exhibited to me the competent evidence of identity as shown below his
name and signature.

ATTY. EMILIA CONCEPCION D. SEVERINO

Notary Public for City of Puerto Princesa
and Province of Palawan
Until December 31, 2016
Roll No. 63949/April 27, 2015
PTR No. 8168136/April 30, 2015
IBP No. 1007335/April 27, 2015
nd
2 Floor Basaya Building, National Highway,
Brgy. San Miguel, Puerto Princesa City
Doc. No.:________
Page No.:________
Book No.:________
Series of 2015