Republic of the Philippines}

Dumaguete City } S.S.

AFFIDAVIT OF LOSS

I, Maria Ana Obuta, married, of legal age, Filipino, and a resident of

Habitat 3, Bajumpandan, Dumaguete City, Negros Oriental, after having
been sworn to in accordance with law depose and state as follows:

1. I pawned a Gold Bracelet weighing 1.9 grams at CEBUANA

LHUILLIER, last June 25, 2020, valued at Php 3,900.00;

2. I was issued a receipt with Receipt No. 40523sg014697;

3. I could no longer locate the receipt as it was inadvertently lost or

misplaced.

4. Despite diligent efforts to recover and find the lost receipt, all efforts
remain futile.

5. I am executing this affidavit to attest to the truthfulness of the facts

above mentioned for whatever legal purpose it may serve.

Nothing follows.

Maria Ana Obuta

Affiant

SUBSCRIBED and sworn to before me, a Notary Public for the City of
Dumaguete and the Municipalities of Sibulan, Valencia, Bacong, Dauin,
Zamboanguita and Siaton, this _________________ at Dumaguete City,
personally appeared Maria Ana Obuta, exhibiting to me her SSS ID No.
33-3403308-3 as proof of identity, known to be the same person who
executed the foregoing attestation, signed by her and acknowledged to me
that the same is her free and voluntary act and deed

Doc. No. ______;

Page No.______;
Book No.______;
Series of: 2020.