REPUBLIC OF THE PHILIPPINES )

Province of Negros Oriental )

City of Dumaguete )S.S.
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AFFIDAVIT OF LOSS OF PAWN TICKET

I, LUCYPE O. MACAY, Filipino, of legal age, single, and a resident of Cadawinonan,

Dumaguete City, Philippines, after being duly sworn in accordance with law, depose and
state:

1. That on February 11, 2016, I pawned my ring at MLhuiller Pawnshop and for which I
was issued Pawn Ticket with Receipt No. 0151-2016-00441.

2. That sometime in the first week of August 2017, when I was looking for the pawn
ticket inside my wallet, I could no longer find the same and I believe that said Pawn
Ticket was misplaced and got lost.

3. That despite diligent search and efforts to locate the said 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 9th day of October 2017, at
Dumaguete City, Philippines.

LUCYPE O. MACAY
Affiant

SUBSCRIBED AND SWORN to before me, this 9th day of October 2017 in the City of
Dumaguete, affiant exhibiting before me her SSS ID with No. 07-3301347-4.

Doc. No. ______;

Page No. ______;
Book No. ______;
Series of 2017.