REPUBLIC OF THE 

PHILIPPINES )
PROVINCE OF ILOILO ) S.S
MUNICIPALITY OF OTON )
x-------------------------------------x
  
AFFIDAVIT OF LOSS

I, BELCHER M. CARNAJE, of legal age, Filipino, and with

residence and postal address at Barangay Cabolo-An Sur, Oton,
Iloilo, Philippines, after having been duly sworn to in accordance with
law depose and say:

1. That I have pawned my ring bond with 2 colors (2.10 grams)

with R.D. Pawnshop at Barangay Jibao-an Sur, Mandurriao,
Iloilo City, Philippines, for and in consideration of the sum of
Php2, 320 and as evidence thereof said pawnshop issued to
me Ticket/Receipt bearing No. 17573774 dated May 14, 2021.

2. That the above said ticket/receipt was unfortunately lost or

misplaced by me and diligent search proved futile;

3. That I am executing this affidavit to attest 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 not assigned nor encumbered the afore-said

ticket/receipt and I hereby free and discharge the pawnshop
from any liability whatsoever by reason of its authorized use
prior to this notice.

IN WITNESS WHEREOF, I have hereunto set my hand this 25 th

of May in Barangay Poblacion North, Oton, Iloilo Philippines.
 BELCHER M. CARNAJE
Affiant

SUBSCRIBE AND SWORN to before me this 25th of May in

Oton, Iloilo, Philippines with affiant exhibiting his Tin No. 123-456-789
and who is personally known to me and personally signed the
foregoing instrument before me and avowed under penalty of law to
the whole truth of the content of the said instrument.

Witness my hand and Notarial Seal.

REYNALD L. TORRES
Notary Public
J. P. Laurel Street, Oton, Iloilo
5020
Telephone No. 123-4567
Roll No. 123456
IBP No. 12345, 05/15/21, Iloilo
City
PTR No. 1234567, 05/15/21
Iloilo City
MCLE Compliance No. V1234567

Doc. No. 02;

Page No. 06;
Book No. 11;
Series of 2021.