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REPUBLIC OF THE PHILIPPINES)

QUEZON CITY, METRO MANILA)S.S.

A F F I D A V I T OF LOSS

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 ____