REPUBLIC OF THE PHILIPPINES)

PROVINCE OF SURIGAO DEL SUR) s.s.

MUNICIPALITY OF TAGO….)

AFFIDAVIT OF LOSS
(Pawnshop Receipt)

I, CHRIS BONYVI V. TARONG, Filipino, of legal age and a

resident of Badong, Tago, Surigao del Sur, Philippines, after having been
duly sworn to in accordance with law, depose and state:

1. That I was issued a receipt with PT No.12698 by the Palawan

Pawnshop at Gamut, Tago, Surigao del Sur sometime in December 2017,
for pledging thereat one (1) ring in the amount of PhP 4,500.00;

2. That just recently, I found out that said Pawnshop Receipt was
missing. All efforts to locate the same, proved to be in vain;

3. That I have not sold, alienated or pledged the said Pawnshop

Receipt in favour of any person and I absolve the Palawan Pawnshop at
Gamut, Tago, Surigao del Sur, from any liability and hold myself solely
liable should any third party claim ownership over the article described
above;

4. I am executing this Affidavit of Loss to attest the veracity of the

foregoing and for whatever legal purpose this may serve best under the
circumstances.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 26th

day of January, 2018 at Tago, Surigao del Sur, Philippines.

CHRIS BONYVI V. TARONG

Affiant

SUBSCRIBED AND SWORN TO before me this 26th day of January,

2018 at Tago, Surigao del Sur, Philippines.