REPUBLIC OF THE PHILIPPINES )

MAKATI CITY, METRO MANILA)S.S.

AFFIDAVIT OF LOSS
THAT I, _____________________, Filipino citizen, of legal age, single and
presently residing at _______________________________after having been duly sworn
to in accordance with law do hereby freely depose and say:
1. That on ______________ I pawned my Nokia
________________________ with pawn ticket no. _____________;

cellphone

with

2. That last __________________, the said pawnshop receipt has been stolen or
misplaced unintentionally;
3. That I have not pledged, encumbered, nor sold the pawnshop receipt and the
items covered therein to any person;
4. That I shall protect, guarantee and insure unto the pawnshop pledge as well as
be subrogated in the pawnshop place against any and all kinds of damages, monetary or
otherwise which may be brought against the pawnshop as a result of this redemption or
renewal;
5. That I shall be personally liable for any claim of/or to third parties as a result of
this redemption or renewal; and
6. That I have executed this affidavit for the purpose of obtaining a replacement
thereof or redeeming said jewelry without the said pawnshop receipt.
IN WITNESS WHEREOF, I have hereunto affixed my signature below this
_________ day of _____________, 2004, here at Makati City, Metro Manila.

____________________________
Affiant
SUBSCIBED AND SWORN to before me this ______ day of July, 2004, here at
Makati City, Metro Manila affiant exhibiting to me his TCT No. ______________, issued
at _________________ on ________________.

DOC. NO. _____;

PAGE NO._____;
BOOK NO._____;
SERIES OF 2004.

NOTARY PUBLIC