Republic of the Philippines)Province of La Union) S.S.City of
San Fernando)x - - - - - - - - - - - - - - - - - - - - - - - x
AFFIDAVIT OF LOSS
I, MARIO DE JESUS, Filipino, of legal age, married, and a
resident of Paringao, Bauang, La Union, Philippines, after being
duly sworn in accordance with law, depose and state:
1. That sometime on December 2014, I pawned a 21K Necklace with
pendant with Cebuana Lhuillier located at San Fernando City, La
Union and for which I was issued Pawn Tickets / Receipt No.
20608SG11365.
2. That sometime on March 5, 2015, my wallet that containing the
said Pawn Ticket was misplaced and got lost.
3. That despite diligent search and efforts to locate the said
wallet and pawn ticket, I could not find the same such that I now
believe that they are now lost beyond recovery.
4. As such, I am executing this Affidavit of Loss to attest to
the truth of the foregoing facts.
IN WITNESS WHEREOF, I have hereunto set my hand this March 13,
2015 at San Fernando City, La Union, Philippines.
MARIO DE JESUS affiant
SUBSCRIBED AND SWORN to before me, this _____________, by the
Affiant who is personally known to me and whom I have identified
through competent evidence of identity.
GILBERT RUIZ HUFANANotary Public until December 31, 2015Roll No.
61392 (03.27.2012)IBP No. 974966 (01.06.2015)PTR No. 0316906
(01.06.2015)TIN 920-960-030
Doc. No. ______;Page No. ______;Book No.______;Series of
2015.
