REPUBLIC OF THE PHILIPPINES )

PROVINCE OF NORTHERN SAMAR )S.S.

MUNICIPALITY OF CATARMAN )
x-----------------------------------------x

AFFIDAVIT OF LOSS

I, MARICEL BENITEZ, of legal age, Filipino, and with residence and

postal address at Mondragon, Northern Samar, Philippines, after having
been duly sworn to in accordance with law depose and say:

That I have pawned my necklace with pendant (5.8 grams) with

Cebuana Lhuillier -Catarman Branch with business address at Catarman,
Northern Samar, Philippines, for and in consideration of the sum of
PhP9,164.00 and as evidence thereof said pawnshop issued to me
Ticket/Receipt bearing No. 60220SG021250, dated January 2, 2017;

That the above-said ticket/receipt was unfortunately lost or misplaced

by me and diligent search proved futile;

That I am executing this affidavit to attest to the truth of the foregoing

circumstances and for the purpose of informing the pawnshop concerned so
that its unauthorized use can be forestalled.

That I have not assigned nor encumbered the afore-said ticket/receipt

and I hereby free and discharge the pawnshop from any liability whatsoever
by reason of its unauthorized use prior to this notice.

IN WITNESS WHEREOF, I have hereunto set my handthis

______________, in Catarman, Northern Samar, Philippines.

MARICEL BENITEZ
Affiant

SUBSCRIBED AND SWORN to before me this __________, in

Catarman, Northern Samar, Philippines, by affiant who is personally known
to me andpersonally signed the foregoing instrument before me and avowed
under penalty of law to the whole truth of the contents of said instrument.
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 2017.