Republic of the Philippines )

City of Kabankalan ) S.S.

x----------------------------------------x

AFFIDAVIT OF LOSS

I, ___________________________________________, of legal age,

single/married/widow/widower, Filipino citizen, and resident of
__________________________________________________, after having been duly sworn in
accordance with law, do hereby depose and say that:

1. I am the owner of jewelry/pieces of jewelry specifically described as follows:

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_______________________________________________;

2. On __________________________, I pawned the above-described piece/s in

_________________________________________________________, for the amount of PhP
___________________;

3. Consequently, Pawn Ticket or Receipt Number _________________________ was

issued by the said pawnshop corresponding to such piece/s;

4. I have recently discovered, however, that the foregoing pawn ticket or receipt
was irretrievably lost and can no longer be found despite diligent efforts to locate the
same;

5. I am executing this Affidavit to attest to the truth of the foregoing statements,

and to redeem or pay the interest for the said piece/s;

IN WITNESS WHEREOF, I have hereunto set my hand this ______________________,

at Kabankalan City, Negros Occidental.

_________________________________________ Affiant

SUBSCRIBED AND SWORN to before me this ______________________, at Kabankalan

City, Negros Occidental. Affiant personally appeared before me, signed the foregoing
document in my presence, and attested under oath as to the truthfulness of the
allegations contained therein.