REPUBLIC OF THE PHILIPPINES )

PROVINCE OF CAMARINES NORTE )S.S.

MUNICIPALITY OF DAET )

AFFIDAVIT OF LOSS
I, Lourdes B. Non, of legal age, Filipino, and a resident of Purok 4, Pasig,
Daet, Camarines Norte, after having been duly sworn to in accordance with law,
hereby state:

That I am the lawful owner of one (1) pair gold earrings and one (1) Pc.
gold necklace;

That I pawned the above items at 999.9 Finegold Pawnshop-Daet Branch

with business address at Daet, Camarines Norte on September 6, 2019 in
consideration of the amount of P8,500;

That 999.9 Finegold Pawnshop-Daet Branch issued Pawn ticket No. 77438
as evidence of the said transaction;

That I previously kept the above indicated pawn ticket safely in my files;

That recently, I noticed that the said pawn ticket is missing and the same
could not be found despite diligent efforts to locate it;

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

and for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 18th

day of October, 2019 at Daet, Camarines Norte.

LOURDES B. NON
Affiant
CRN 006-0031-9534-3

SUBSCRIBED AND SWORN TO BEFORE ME this, 18th day of October, 2019

at Daet, Camarines Norte. Affiant exhibited to me her UMID ID written below her
name as proof of her identity.

ATTY. RONBERT A. RAMOS

NOTARY PUBLIC
Doc. # For and in CAMARINES NORTE
NOTARIAL COMMISSION NO. 2018-14
Page # UNTIL DECEMBER 31, 2019
Attorney Roll No. 71268
Book # 25 PTR NO. CN-9128312 / 12-27-18
Series of 2019 IBP OR NO. 0996982 / 12-28-18
MCLE Compliance No. VI-0022944