REPUBLIC OF THE PHILIPPINES }

ZAMBOANGACITY. }S.S.
X--------------------------------------------X
AFFIDAVIT OF LOSS
I, TONI MARIE SACLOT, of legal age, Filipino, single, and a resident of 29 Aurora Quezon St,
Davao City, after having been sworn in accordance with law, do hereby depose and state:
1. That I pawned a certain necklace with pendant, two toned, 18k weighing 1.6 grams at
Padjak Boonsan located at Brillantes St., this City, sometime last week, in the amount
of P 1,800.00;
2. That I was issued a pawnshop ticket no. 33420 by the said business entity, which I will
present for the retrieval of the said pawned item and the same was kept in my wallet;
3. That when I was about to retrieve the item from said pawnshop, I was surprise to
know that the said receipt was no longer in my possession;
4. That I diligently exerted efforts but the same proved futile, and the pawnshop receipt
could no longer be found, which I hereby declare the same to be lost and beyond
recovery;
5. That I am executing this affidavit to attest to the truth and veracity of the foregoing
statements and for the repossession of the pawned item.
IN WITNESS WHEREOF, I have hereunto affixed my signature this 30 th day of October, at
Zamboanga City, Philippines.
TONI MARIE SACLOT
(Affiant)
Govt Issued ID L02-05-0005252
SUBSCIBED AND SWORN to before me on the above stated date and place.

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