REPUBLIC OF THE PHILIPPINES)

C ITYO F MAKATI ) S.S.

AFFIDAVIT OF LOSS

I, ______________________________, of legal age, Filipino, resident at

___________________________________, after having been duly sworn to in
accordance with law do hereby depose and state:

1. That I am the owner/holder of the PAWN TICKET issued by

______________________________ more particularly described
as follows;

 Pawn Ticket No. : __________

 Principal Amount : __________
 Loan Date : __________
 Expiry Date : __________
 Description : __________________________

2. That sometime ____________________ the said item was

misplaced;

3. That despite the diligent search and efforts to locate the said item, I
could not find the same such that I now have reasons to believe
that it is now lost and can’t be recovered;

4. That I am executing this affidavit to attest to the truth and the

veracity of the foregoing statement in order to inform, to report and
request for whatever legal purpose it may serve.

AFFIANT FURTHER SAYETH NAUGHT

IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of

_______________ at Makati City.

____________________
Affiant

SUBSCRIBED AND SWORN to before me this _____ day of

_______________ at Makati City, Philippines. Affiant exhibited to me
_________________________.

Doc No. ___________

Page No. __________
Book No. __________
Series of 2019