REPUBLIC OF THE PHILIPPINES)

CITY OF MANILA ) S.S.

AFFIDAVIT OF LOSS

I, _________________, of legal age, Filipino, married and a resident at

_______________________, after having been duly sworn to in accordance
with law, depose and state:

1. Sometime on October 12, 2023, I pawned my Earing with Cebuana Lluillier

Pawnshop located at Escolta St., Sta Cruz Manila and for which I was issued
Pawn Ticket No. 60431NP003787 2.2 grams 18k principal amount of P6,325;

2. I kept the said pawn ticket inside my wallet for safekeeping but
unfortunately my wallet got lost;

3. Despite diligent search and efforts to locate the said wallet and pawn
ticket, I could not find the same such that I believe that they are now lost
beyond recovery;

4. As such, I am executing this affidavit to attest to the foregoing facts and

to enable me to secure a duplicate or substitute copy of the ticket and/or
redeem the above-described item which I pawned.

IN WITNESS WHEREOF, I have hereunto set my hand

this _____________ in ____________, Philippines.

_____________
Affiant

SUBCRIBED AND SWORN TO before me

this ___________________ in _________________, Philippines, affiant
exhibiting to me his valid proof of identification.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2023