REPUBLIC OF THE PHILIPPINES )
QUEZON CITY ) S.S.
AFFIDAVIT OF LOSS
I, MARY GRACE MAMTOTE. of legal age, Filipino, married, and a resident of
AREA 6B STREET MICHAEL REPUBLIC AVE. QUEZON CITY, after having been duly
sworn to in accordance with law, hereby depose and say:
That I am the holder of the Pawn Ticket with No. 61660NP001740 issued by
Cebuana Pawnshop, described above;
Descriptions : NECKLACE W/ PENDANT
Amount : P14,025.00
Karat : 18K
Grams : 5.1g
Loan Date : 01/02/2023
Expiry Date : 05/03/2023
That the said Pawn Ticket was lost last April 2023, when I was accidentally
misplacing it;
That I exerted utmost effort to locate the same but proved futile;
That I am executing this affidavit in order to attest the truth of the foregoing facts
and for all legal intents it may serve.
IN WITNESS WHEREOF, I have hereunto set my hand on this 4th day of May
2023 at Quezon City Philippines.
MARY GRACE MAMTOTE
Affiant
SUBSCRIBED AND SWORN to before me 4th day of May 2023 at Quezon City
Philippines.
Doc. No.: _____________ NOTARY PUBLIC
Page No.: _____________
Book No.: _____________
Series of 2023
REPUBLIC OF THE PHILIPPINES )
QUEZON CITY ) S.S.
AFFIDAVIT OF LOSS
I, CAMILLE LORRAINE C EVORA, of legal age, Filipino, single, and a resident of
BLK 1 LOT 4 CEDAR ST. WEST FAIRVIEW QUEZON CITY, after having been duly sworn
to in accordance with law, hereby depose and say:
That I am the holder of Policy Documents with Policy No. F109-4238 of Caritas
Financial Plans, Inc
That the said Policy was lost under circumstances I cannot ascertain and was not
aware of;
That I exerted utmost effort to locate the same but proved futile;
That I am executing this affidavit in order to attest the truth of the foregoing facts
and for all legal intents it may serve.
IN WITNESS WHEREOF, I have hereunto set my hand on this 16 th day of May
2023 at Quezon City Philippines.
CAMILLE LORRAINE C EVORA
Affiant
SUBSCRIBED AND SWORN to before me this 16th day of May 2023 at Quezon
City Philippines.
Doc. No.: _____________ NOTARY PUBLIC
Page No.: _____________
Book No.: _____________
Series of 2023
REPUBLIC OF THE PHILIPPINES )
QUEZON CITY ) S.S.
AFFIDAVIT OF LOSS
I, WILLIAM VERGOSA COGAY, of legal age, Filipino, single, and a resident of BLK
223 LOT 11 PESETA STREET NORTH FAIRVIEW QUEZON CITY, after having been duly
sworn to in accordance with law, hereby depose and say:
1. I am a duly licensed driver in accordance with pertinent Land Transportation
laws, rules and regulations, and was issued a corresponding Non-Professional
Driver’s License with number N23-22-316275 which is valid until January 06,
2027.
2. Sometime in May 17, 2023 around 6 in the evening the said Driver’s License was
lost.
3. That I exerted utmost effort to locate the same but proved futile;
4. That I am executing this affidavit in order to attest the truth of the foregoing facts
and for all legal intents it may serve.
IN WITNESS WHEREOF, I have hereunto set my hand on this 16 th day of May
2023 at Quezon City Philippines.
CAMILLE LORRAINE C EVORA
Affiant
SUBSCRIBED AND SWORN to before me this 16th day of May 2023 at Quezon
City Philippines.
Doc. No.: _____________ NOTARY PUBLIC
Page No.: _____________
Book No.: _____________
Series of 2023
REPUBLIC OF THE PHILIPPINES )
QUEZON CITY ) S.S.
AFFIDAVIT OF LOSS
I, WILLIAM VERGOSA COGAY, of legal age, Filipino, single, and a resident of BLK 223
LOT 11 PESETA STREET NORTH FAIRVIEW QUEZON CITY, after having been duly sworn to in
accordance with law, hereby depose and say:
1. I am the registered owner of a motor vehicle which is particularly described as follows:
Make & Type: KAWASAKI
Engine Number: BC175AEBV1129
Chassis Number: BC175M-B06816
Plate Number: 710UNT
MV File No.: 1366-00000499665
Year Model/Color: 2022
2. As proof of ownership of the above-described vehicle I was issued by the MOTORTRADE ABAD
SANTOS, Official Receipt (OR) and Certificate of Registration (CR);
3. The said documents while in my possession were misplaced and could no longer be located in
spite of diligent efforts to locate them;
4. Said documents were not confiscated by any government authorities for violation of R.A. 4136
and other related laws;
5. I shall assume responsibility or liability if in any event I will use these documents for whatever
illicit transactions;
6. I am executing this affidavit to attest to the veracity of my statements and to support my request
for duplicate copies of the lost OR/CR.
IN WITNESS WHEREOF, I have hereunto set my hand on this 18th day of May 2023 at
Quezon City Philippines.
WILLIAM VERGOSA COGAY
Affiant
SUBSCRIBED AND SWORN to before me this 18 th day of May 2023 at Quezon City
Philippines.
Doc. No.: _____________ NOTARY PUBLIC
Page No.: _____________
Book No.: _____________
Series of 2023
