REPUBLIC OF THE PHILIPPINES)

PROVINCE OF GUIMARAS ) S.S.

x----------------------------------------------x

AFFIDAVIT OF LOSS
I, CHARMAINE G. FERRER, of legal age, single, Filipino, and a resident Brgy.
Daragan, Buenavista, Guimaras, Philippines, after having been duly sworn to in accordance
with law, hereby voluntarily depose and state;

1. That I am the holder/owner of a lost MLhuillier Pawnshop Receipt described as

follows;

Receipt No. : 0543-2021-00205

Amount : Php 3,000.00
Date Pawned : January 25, 2021
Description : 1 YG PR Creolla Deformed Def; 21K; 1.3g

2. That despite diligent search and efforts to locate the said MLhuillier Pawnshop
Receipt the same could no longer be found such that I now believe that it is now lost
beyond my recovery;

3. That I am executing this Affidavit to attest to the truth of the foregoing statements and
for all legal intents and purposes it may serve.

IN WITNESS WHEREOF, I hereunto affixed my signature this 26th day of March, 2021
at the Province of Guimaras, Philippines.

CHARMAINE G. FERRER
Affiant
Resident ID No. 030107056110

SUBSCRIBED AND TO SWORN to before me on the date and place indicated

above. Affiant exhibited to me her Resident ID with No. 030107056110.

Notary Public

Doc. No. 240;

Page No. 049;
Book No. XIX;
Series of 2021