Republic of the Philippines)

Province of Samar )S.S

City of Catbalogan )

AFFIDAVIT OF LOSS

I, NATHALEEN JOY D. TAN, of legal age, Filipino, single with residence and postal
address at Barangay 04, Catbalogan City, Samar, after having been duly sworn to in accordance
with law depose and say:

1. That I have pawned my PUCERA BI COLOR DES JI/5.9 in Cebuana Lhuiller with
business address at Allen Avenue, Catbalogan City, Western Samar for and in
consideration of the sum of Php 11,357.50 and as evidence thereof said Pawnshop issued
to me Pawn Ticket No. 40606SG054651 dated May 06, 2019;

2. That the above-said pawn ticket/receipt was unfortunately lost or misplaced by me and
diligent search proved futile;

3. That I am executing this affidavit to attest to the truth of the foregoing circumstances and
for the purpose of informing the pawnshop concerned so that its unauthorized use can be
forestalled;

4. That I have assigned nor encumbered the afore-said pawn ticket/receipt and I hereby free
and discharge the pawnshop from any liability whatsoever by reason of its unauthorized
use prior to this notice.

IN WITNESS WHEREOF, I have hereunto set my name this ____ day of ____________,
in Catbalogan City, Samar, Philippines.

NATHALEEN JOY D. TAN

Affiant

SUBSCRIBED AND SWORN to before me this _____ day of ________________ in

Catbalogan City, Samar, Affiant exhibited to his/her ____________________ - issued at
________________ on _________________________.

Doc. No. ___;

Page No. ___;
Book No. ___;
Series of 2019.