Republic of the Philippines)

___________________
) S.S
___________________
)
x--------------------------x

AFFIDAVIT OF LOSS
I, ______________________, of legal age, Filipino, married and
a resident of _________________________, under oath state:
1.

That I am the holder of a Pawnshop

Ticket/Receipt No. _________________ for my
jewelries
_______________
pawned
at
______________________
on
_________________________;

2.

That I kept the said pawnshop ticket inside my

wallet for safekeeping;

3.

That recently when I looked for the said

ticket/receipt, I discovered that it got lost and
could not be found anywhere, believing it might
have been misplaced somewhere else or might
have fallen from my wallet without my notice;

4.

That despite due and diligent search and effort

to look the said pawn ticket/receipt, my effort
only proved futile as it is now deemed lost
beyond recovery;

5.

That I am executing this affidavit to attest to

the truth of the foregoing and for whatever
legal purposes this affidavit may serve best.

IN WITNESS WHEREOF, I hereunto affixed my signature

this ________________________ at __________________________.

__________________________
__

__________________

Affiant

ID
_____________________
Issued

No:
at:

SUBSCRIBED AND SWORN to before me this

____________________ at ________________________________ by
affiant who is personally known to me and further exhibited his
competent identification as shown above.