REPUBLIC OF THE PHILIPPINES ) PROVINCE OF CAMARINES NORTE)SS.

MUNICIPALITY OF DAET )

AFFIDAVIT OF LOSS I, __________________________, of legal age, single/married/widow/widower, Filipino citizen, and a resident of _______________________________________________, after having been sworn on oath in accordance with law, hereby voluntarily depose and say: That I pledged with ___________________ ________________________ the following items, to wit: Date Description Pawnshop, located at

Amount

Ticket Number

That said pawn tickets corresponding to above-described items were lost and cannot be recovered despite diligent efforts to locate it; That I am executing this statement to attest to all the above facts, to request the ________________________ Pawnshop to allow me to facilitate the renewal or redemption of above-mentioned pawned items; IN TRUTH WHEREOF, I have hereunto signed my name below, this __________________, at Daet, Camarines Norte.

_________________________ Affiant SUBSCRIBED AND SWORN to before me, this ________________, at Daet, Camarines Norte. Doc. No.__________ Page No.__________ Book No._________ Series of 2008