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REPUBLIC OF THE PHILIPPINES)

QUEZON CITY, METRO MANILA)S.S.


AFFIDAVIT
I,
_____________________,of
legal
age,
Filipino/_______________,
single/married to _____________________ with residence and postal address at
________________________________, after having been duly sworn to in accordance
with law depose and say:
That
I
have
pawned
my
____________________
with
___________________Pawnshop
with
business
address
at
_________________________ for and in consideration of the sum of PhP
__________________and as evidence thereof said Pawnshop issued to me
Ticket/Receipt No.______________ dated _____________;
That the above-said ticket/receipt was unfortunately lost or misplaced by me and
diligent search proved futile;
That I am executing this affidavit to attest to the truth of the foregoing
circumstances and for the purpose of informing the pawnshop concerned so that its
unauthorized use can be forestalled.
That I have not assigned nor encumbered the afore-said ticket/receipt and I hereby
free and discharge the pawnshop from any liability whatsoever by reason of its
unauthorized use prior to this notice.
IN WITNESS WHEREOF, I have hereunto set my name this ___ day of
__________________________, in Quezon City, Metro Manila, Philippines.

Affiant
SUBSCRIBED AND SWORN to before me his ____ day of
______________________________ in Quezon City, Metro Manila, Philippines, Affiant
exhibited to me his/her CTC No. _______________- issued at ___________________ on
_____________________.

Doc. No. _____;


Page No. _____;
Book No. _____;
Series of 200__.
legal forms\affidavit of lost pawnshop receipt