Republic of the Philippines)

_____________________ ) s.s.

AFFIDAVIT OF LOSS
CEBUANA PAWNSHOP OFFICIAL RECEIPT

I, Filipino, of legal age, and presently residing at B3 L7 St. Joseph Drive La Trinidad,
Quezon City after having been sworn to in accordance with law, do hereby depose and
state that:

1. An Official Receipt (claim stub) WAS ISSUED BY CEBUANA ;

2. Unfortunately, I discovered that said Official Receipt was inadvertently

misplaced/ lost.

3. In spite of all efforts to recover it, the same was nowhere to be found and should
therefore be considered lost.

I am executing this affidavit to attest to the truth of the foregoing.

.

Done this July 22, 2017 at the City of Manila, Philippines.

Affiant

SUBSCRIBED AND SWORN to before me this July 22, 2017, at the City of Manila,
Philippines, affiant exhibiting to me her -8

Page No
Book No 21
Series of 2017