REPUBLIC OF THE PHILIPPINES )

Province of Negros Oriental )

City of Dumaguete )S.S.
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AFFIDAVIT OF LOSS

I, MAY ANN GELLY SUBRAR, Filipino, of legal age, single and a resident of
Pamplona, Negros Oriental, Philippines, after being duly sworn in accordance
with law, depose and state:

1. That sometime on August 2019, I pawned my WG Ring Titus with RD

Pawnshop in Dumaguete City and for which I was issued Pawn Ticket
No. 08456285 with the amount of P4,000;

2. That the said receipt was placed in my wallet. However, around last
week, my wallet fell off from my pocket while I was in Dumaguete City;

3. That I tried to trace back my path but to no avail;

4. That despite diligent search and efforts to locate my wallet with the said
receipt in it, I could not find the same such that I now believe that it is
now lost and beyond recovery;

5. As such, I am executing this Affidavit of Loss to attest to the truth of the

foregoing facts and for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this October 10,

2019 at Dumaguete City, Philippines.

MAY ANN GELLY SUBRAR

PRC ID 0859537
Affiant

SUBSCRIBED AND SWORN to before me, this October 10, 2019 in the City of
Dumaguete, affiant exhibiting me a valid proof of identity as shown above.

Doc. No. _____;

Page No. ;
Book No. _____;
Series of 2019.