REPUBLIC OF THE PHILIPPINES)

CITY/MUNICIPALITY OF _____ ) S.S.

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

AFFIDAVIT OF LOSS

I, ___________________, of legal age, Filipino, single and a resident of

_______________________________, after having been duly sworn to
in accordance with law, depose and state THAT:

1. Sometime on ______________, I pawned my _________ with Tambunting

Pawnshop located at _____________________ and for which I was issued
Pawn Ticket/Receipt No. _________;

2. I kept the said pawn ticket in my wallet for safekeeping but unfortunately
my wallet got lost;

3. Despite diligent search and efforts to locate the said wallet and pawn ticket,
I could not find the same such that I believe that they are now lost beyond
recovery;

4. As such, I am executing this affidavit to attest to the foregoing facts and to

enable me to secure a duplicate or substitute copy of
the ticket and/or redeem the above-described item which I pawned.

IN WITNESS WHEREOF, I have hereunto set my hand

this ___________________ in ____________, Philippines.

____________________

Affiant

GSIS ID No. _____________

SUBCRIBED AND SWORN TO before me this ___________________ in

_________________, Philippines, affiant exhibiting to me his valid proof
of identification.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2013.