Republic of the Philippines )

Province of Palawan
) S.S
Municipality of Taytay
)

AFFIDAVIT OF LOSS
I, RODENICK R. AGUDA , Filipino, of legal age, Married, with postal
address at Barangay Pancol Taytay, Palawan, Philippines After being duly sworn
in accordance with law, hereby depose and state:
a. That on April 16, 2016 I have pawned several jewelry at M LHUILLIER
PAWNSHOP- Taytay Branch with the following transaction code:
i. 830-2016-00209;
ii. 830-2016-00208; and
iii. 830-2016-00207
b. That I have discovered just today, that the said pawn tickets were
missing;
c. That efforts to locate the same proved futile, hence said pawn ticket is
now beyond recovery;
d. As such, I am executing this Affidavit of Loss to attest to the truth of the
foregoing and for whatever legal purpose this may serve.
IN WITNESS WHEREOF, I have hereunto set my hand this 15th day of
September 2016 at Poblacion, Taytay Palawan.

RODENICK R. AGUDA
Affiant
SSS ID No. 04-3085792-0
SUBSCRIBED AND SWORN to before me this 15th day of September 2016
at Poblacion, Taytay, Palawan. Affiant exhibited to me the competent proof of
identity as shown below his name and signature.

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