Republic of the Philippines )

Camiling Tarlac ) S.S.

AFFIDAVIT OF LOSS
I, MARICAR S. URZAME, 25 years old, Filipino citizen, and a resident of
Barangay Nagserialan, Camiling, Tarlac, Philippines, after having been duly sworn to
in accordance with law, do hereby depose and state THAT:

1. On July 5, 2016, I pawned my jewelry at the St. Patrick Pawnshop located

at Luna St., Camiling,Tarlac and I was issued pawn ticket with number
18943;

2. After my transaction with the said pawnshop, I placed the said ticket inside
my wallet and went home;

3. Recently, I was about to renew my pawn when I discovered that the

above-said pawn ticket was missing from my wallet. I thoroughly searched
the contents of my wallet hoping that the said pawn ticket was mixed with
my other personal belongings but I found nothing

4. All my diligent efforts to locate the said ticket proved futile; hence, I now
consider the same as lost and beyond recovery;

5. I am executing this Affidavit to attest to the truth of the foregoing

statements with the intent of renewing the pawn covered by such ticket
even in the absence of the said ticket and for whatever legal intents and
purposes this may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 3rd day of

October, 2016 at Camiling, Tarlac, Philippines.

MARICAR S. URZAME
Affiant

SUBSCRIBED AND SWORN to before me on the date and place indicated

above. Affiant exhibited before me her School ID Card bearing her Student Number
1500655 issued by the CIT Colleges, Paniqui, Tarlac.

Doc. No.________;
Page No._______;
Book No._______;
Series of 2016.