REPUBLIC OF THE PHILIPPINES)

PROVINCE OF CEBU ) S.S.

AFFIDAVIT OF LOSS
I, , of legal age, Filipino, married and a resident of Yati, Liloan Cebu, after having
been duly sworn to in accordance with law, do hereby say, T H A T:

1. I am the bonafide holder/owner of an MLhuillier Receipt with the following

items that I pawned:

Item lost: Receipt of a Ring, MLhuillier Receipt no:0332-2019-00288

Amount:5,100.00
Date Pawned: March 04,2019
Description:1 ring YG
DEF:14K 3.90grams

2. Last week, I rode a public utility vehicle bound for Liloan, Cebu from Cebu
City. When I was about to give my fare, I realized that my wallet, which
contains the above-mentioned receipt, was no longer in my pocket.
3. Immediately, I searched on my belongings and even talked to the driver of the
PUV if he has seen the above-mentioned but he answered in negative. I
realized that the wallet might have fallen off while I was walking the
sidewalks.
4. I exerted diligent effort to locate the same, in the vain hope that the
abovementioned thing could be recovered, hence, the aforesaid things are
considered lost forever.
5. The said Receipt was not used for illegal purposes nor confiscated by
authorities.
6. Finally, I am executing this affidavit of loss in order to inform MLhuillier of the
fact of loss, that the same is not used for illegal purposes and that I be issued
a new receipt or be allowed to claim my pawned items.

IN WITNESS WHEREOF, I hereby affix my signature, this February 3, 2020 at Lilo-

an Cebu, Philippines.

Affiant

SUBSCRIBED AND SWORN TO before me, this February 3, 2020 at Lilo-an Cebu,
Philippines, affiant exhibited to me her competent proof of identity indicated as : CTC issue
in Tipolo Mandaue.

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Series of 2020.