REPUBLIC OF THE PHILIPPINES)

CITY OF DIPOLOG )S.S

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AFFIDAVIT OF LOSS

KNOW ALL MEN BY THESE PRESENTS:

I, MARY JOY F. SALUTA, Filipino, of legal age, married, and a resident of Sepac, Sapangdalaga,
Misamis Occidental, after having sworn to in accordance with law, depose and say that:

I had been in possession of OR number 0532-2021-00149 issued by Mlhuiller as proof of my pawned

earrings bearing the description 1.00 YG Earring DEF by 105 2.40 G;

That the same earrings was pawned last April 5, 2021 with an amount of P5, 600;

That the above-mentioned OR was lost;

Despite earnest efforts exerted by me, the same could no longer be found nor recovered;

I am executing this affidavit in good faith and in accordance with law, to attest to the fact of
the loss of aforementioned OR.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 7th day of October, 2021 at
Dipolog City, Philippines.

MARY JOY F. SALUTA

_______________________
Affiant

SUBSCRIBED, SIGNED, AND SWORN TO in my personal presence, this 7 th day of October,

2021, at Dipolog City, Philippines, affiant presenting her competent proof of identity, the particulars
of which are above-cited, and who avowed under penalty of law to the whole truth of the contents of
the instrument or document, which she executed freely and voluntarily.

Doc. No. _____;

Page No. _____;
Book No._____;
Series of 2021.