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REPUBLIC OF THE PHILIPPINES)

MUNICIPALITY OF HILONGOS) S.S.


PROVINCE OF LEYTE)
AFFIDAVIT OF LOSS
I, VIRGINIA L. DATOR, Filipino, of legal age, single, and a resident of Hilongos,
Leyte, after being duly sorn to in a!!ordan!e it" la, "ereby depose and say#
$. T"at I paned a ring it" %la!& 'earl at t"e (ebuana L"uillier, Hilongos %ran!" for
an a)ount of '*,+++.++,
-. T"at for said paned ite), I as issued a re!eipt, "i!" I used to &eep at our
residen!e,
.. T"at so)eti)e last De!e)ber $/, -+$-, I noti!ed t"at t"e said re!eipt as no"ere
to be found,
0. T"at I e1erted diligent efforts to find and re!o2er t"e sa)e but all )y efforts pro2ed
futile, "en!e I a) de!laring t"e said re!eipt as lost and beyond re!o2ery,
/. T"at I a) e1e!uting t"is sorn state)ent, to attest to t"e trut" of t"e foregoing fa!ts
for t"e purpose of obtaining a repla!e)ent for t"e sa)e.
IN 3ITN455 3H4R4OF, I "ereby set )y "and t"is -/t" day of 6ar!", -+$. at Hilongos,
Leyte, '"ilippines.

VIRGINIA L. DATOR
Affiant
57%5(RI%4D AND 53ORN to before )e t"is -/t" day of 6ar!", -+$. at Hilongos,
Leyte, '"ilippines, affiant e1"ibiting to )e 555 ID No. +89-$8.$.+9:.
EFREN B. MENDOZA
Do!. No. $:. Notary 'ubli!
'age No. .: 7ntil De!e)ber .$, -+$0
%oo& No. ;;III I%' No. <$/0/., =an. :, -+$., Ta!loban (ity
5eries of -+$. 'TR No.'L8$<+:+*, =an. -<, -+$., Hilongos, Leyte
Roll No. /+++/
TIN <+89<-/9+00