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Republic of the Philippines)

Tarlac City ) S.S.

AFFIDAVIT OF LOSS
I, JUDD DAVID, Filipino, of legal age, and a resident of San Rafael, Tarlac City, after
having been duly sworn to in accordance with law, do hereby depose and say:

1. That I mortgaged the following item at Cebuana Lhuillier Pawnshop located at M. H.


Del Pilar St., Sto. Cristo, Tarlac City;

a.) 1 pc of wedding ring amounting to THREE THOUSAND FOUR HUNDRED


TEN PESOS (P3,410.00), with Pawnticket No. 21105SG028106 loan dated Feb. 2,
2018;

b.) 1 pc of wedding ring amounting to THREE THOUSAND FOUR HUNDRED


TEN PESOS (P3,410.00), with Pawnticket No. 21105SG028152 loan dated Feb. 07,
2018;

c.) 1 pc of ladies ring Tiffany amounting to THREE THOUSAND TWO HUNDRED


TEN PESOS (P3,210.00), with PawnTicket No. 21105SG028022 loan dated Jan. 25,
2018;

2. That I lost said official receipt and despite diligent effort on my part to locate it, the
same could no longer be found;

3. That I now consider said official receipt lost and beyond recovery;

4. That I am executing this affidavit to inform the proper authority concerned about said
lost and for whatever legal purpose this affidavit may duly serve.

IN WITNESS whereof, I have hereunto set my hand this 17th day of April 2018 at
Tarlac City, Philippines.

JUDD DAVID
Affiant

SUBSCRIBED AND SWORN to before me this 17th day of April 2018 at Tarlac City,
Philippines, by Affiant who exhibited to me his Competent Evidence of Identity with details as
follows:

Name Competent Evidence of Identity Date/Place of Issued


JUDD DAVID Drivers License No. C1112000054

WITNESS MY HAND AND SEAL

ATTY. KARLA FLOR D. FONACIER


NOTARY PUBLIC
UNTIL DECEMBER 31, 2019
APPT. NO. N-266-18, TARLAC CITY
IBP No. 012830 LIFETIME, MAY 13, 2014
PTR NO. 3382419, JAN. 24, 2018
SC. ROLL NO. 62968
G5 JRT BLDG. M.H. DEL PILAR STREET
BRGY. LIGTASAN, TARLAC CITY

Doc. No. 422


Page No. 86
Book No. 35
Series of 2018