Republic of the Philippines)

City of Lapu-Lapu )S.S

AFFIDAVIT OF LOSS

I, _________, of legal age, Filipino, married, and a resident of _________________, after having
been duly sworn in accordance with law, hereby depose and state:

1. That sometime last January 2, 2023, I pawned my 24-inch gold necklace with a pendant and a
16-carat gold bracelet with charms at P_______________, located at ___________________;

2. That in exchange, the above-mentioned establishment duly issued a pawn ticket in my favor;

3. That I kept the said pawn ticket inside my car for safekeeping and easy access;

4. That sometime last February 5, 2023, I decided to retrieve the above-described items, but I can
no longer find the pawn ticket that I kept inside my car;

5. That I immediately searched for the ticket in all the possible places it could be, but all to no
avail;

6. That after exerting my utmost diligent effort to locate the said pawn ticket and failing, I am
constrained to believe that it is lost beyond recovery;

7. I am executing the instant Affidavit to attest the veracity of the foregoing statements and for
whatever legal purpose this may serve best;

IN WITNESS WHEREOF, I have hereunto affixed my signature this 24 th day of February 2023 at Lapu-
Lapu City, Philippines.

_______________________
Affiant

SUBSCRIBED AND SWORN to before me this 24TH day of February 2023 at Lapu-Lapu City,
Philippines, affiant with her Unified Multi-Purpose ID with ID No. _______________________, personally
known to me to be the same person who executed the foregoing affidavit and who signed this instrument in my
presence, and avowed under the penalty of law to the whole truth of its contents.

Doc. No. ____;

Page No. ___;
Book No. ____;
Series of 2023.