REPUBLIC OF THE PHILIPPINES PROVINCE OF QUIRINO MADDELA/NAGTIPUNAN

) )S.S )

AFFIDAVIT OF LOSS I, GWEN DIZON , of legal age, Filipino, married/single, presently residing at Poblacion Norte ,Maddela, Quirino, after being been duly sworn to in accordance with law do hereby depose and say the following to wit: 1.That I am owner and pawner of an item described on the pawn ticket as one pair of earring yellow gold 21k and one piece bracelet yellow gold 21k, 6.1grams modern amount of Php7,500, which I pawned at TAMBUNTING PAWNSHOP Maddela,Quirino, and for which I was issued Pawnshop Ticket No. 3357 with Loan date on October 22, 2010 and maturity date on February 22,2011, 2.That I kept the said pawn ticket inside my bag for sake keeping but unfortunately the said pawn ticket was misplaced, 3.That the Pawn ticket No. 3357 issued to me by TAMBUNTING PAWNSHOP was misplaced, 4.That despite of all efforts to find the said Pawn Ticket, I still cannot Locate it and consider it lost forever, 5.That I am executing this affidavit to attest the truth of all forgoing and to enable me to secure a duplicate or substitute copy of ticket and/or redeem the above-described item which I pawned.

IN WITNESS WHEREOF, I have hereunto affixed my signature hand this 22th day of February 2011 at Maddela, Quirino. GWEN DIZON Affiant

SUBSCRIBED AND SWORN to before me this 22th day of February 2011,affiant having exhibited her Community Tax Certificate No.________issued on ________ at Maddela, Quirino, Philippines.

Doc. No. ________ Page No. ________ Book No. _______ Series of 2011

JUNARD N. RAMOS Notary Public Maddela/Nagtipunan PTR.No. 0010983/01.03.11/Maddela IBP No.753926/12.22.10/Quirino Admin. Matter No.2009-2/Until Dec.31, 2011 Lawyers Roll No. 52289 MCLE Compliance No. 111-6090/11.11.09 Poblacion Norte, Maddela, Quirino