Republic of the Philippines)

Province of Negros Oriental) S.S.

Municipality of Sibulan. . . . . . .)

AFFIDAVIT OF LOSS (PAWN TICKET/RECEIPT)

I, MARIA JASMIN P. TUBAN, of legal age, Filipino, married and resident of Maslog,
Sibulan, Negros Oriental, after being duly sworn to in accordance with law, hereby depose and say
that:

1. I was previously issued a pawn ticket/receipt by MLhuillier Philippines, with the

following information:

Date: 09-26-2022
Name: Maria Jasmin P. Tuban
Complete Address: Maslog, Sibulan, Negros Oriental
Receipt No.: PTN 0975-2022-01153
Amount: 27, 700
Date Pawned: August 25, 2022
Descriptions(s): 1 YG NECKLACE DEF. 18k 10.6 grams
Tel. No.: 09360924824

2. However, the said pawn ticket or receipt was inadvertently lost. Perhaps, it was
misplaced;

3. Inspite of diligent search and efforts to look for said pawn ticket, all such efforts
proved in vain, thus I am now declaring the loss of said pawn ticket.

4. I never sold, alienated conveyed or pledged the said receipt or pawn ticket in favor of
any person and I hereby release the said Pawnshop from any liability and hold myself liable should
any third person claim ownership over the said pawned article.

5. I am executing this affidavit to attest to the truth of the foregoing facts and for all its
legal intents, effects, consequences and purposes, including to redeem or renew said pledge.

IN WITNESS WHEREOF, I have hereunto set my hand this ___________________ in

Sibulan, Negros Oriental, Philippines.

MARIA JASMIN P. TUBAN

Affiant

SUBSCRIBED AND SWORN to before me, a Notary Public, on this _________________,

for the Municipality of Sibulan and the Province of Negros Oriental, Philippines, the above-named
affiant, who is personally known to me, and WHO SIGNED IN MY PRESENCE the foregoing
document (Affidavit of Loss), and who avows under PENALTY OF LAW to the whole truth of the
contents of the same.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2022.