REPUBLIC OF THE PHILIPPINES)

) S.S.

AFFIDAVIT OF LOSS

That I, LEOVIE MARQUILENCIA SUSA, of legal age, Filipino Citizen, and with
address at #186 LOT 9 A4 SQUARE VILLE EXECUTIVE HOMES DAO ST.,
MARIKINA HEIGHTS, MARIKINA CITY, after having been duly sworn to in
accordance with law do hereby depose and say:

That I am the holder CEBUANA LHUILLIER PAWN TICKETS NO.

60500SG027596 and 60500SG027597 issued by CEBUANA LHUILLIER BAYAN-
BAYANAN.

That sometime on APRIL 20, 2020 the said PAWN TICKETS was lost, due to
unexpected circumstances;

That diligent effort was exerted to locate the same but it yielded a negative result:

That I am executing this affidavit of loss to attest the truth of the foregoing facts and
for reporting/for replacement/ and for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

_____________________________, ______________________, Philippines

LEOVIE MARQUILENCIA SUSA

Affiant

SUBSCRIBED AND SWORN to before me this___________________ affiant

exhibiting to me his/ her CTC No. __________________ issued on ______________ at
_____________ Philippines.

Doc No. ________

Page No. ________
Book No. ________ Notary public
Series of 2020