REPUBLIC OF THE PHILIPPINES)

Pasig City ) S.S.

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

AFFIDAVIT OF LOSS

I, NELY A. SALVADOR, of legal age, Filipino, married and a resident of No. 30-A J. Ramos St.,
Ibayo-Tipas, taguig City, after having been duly sworn to in accordance with law, depose and
state THAT:
1. I pawned a necklace, wedding ring and a lady’s ring at Cebuana Lhullier Pasig last June 20,
2016 evidenced by pawn receipt number 10921SG032644, 10921SG032645 and
10921SG032646 respectively;

2. Sometime on September 30, 2016, said pawn receipts was misplaced and got lost;

3. Efforts were exerted to locate said pawn receipts, but in spite of diligent search, it could not
be found and the same is now beyond recovery;

4. Said pawn receipts has not been sold or transferred to another person;

5. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing and to
support my application for the re-issuance of another pawn receipt, in lieu of the one that was
lost;

IN WITNESS WHEREOF, I have hereunto set my hand this ___________________ in Pasig City,
Metro Manila, Philippines.

NELY A. SALVADOR
Affiant
SSS ID No. _____________

SUBCRIBED AND SWORN TO before me this ___________________ in _________________,

Philippines, affiant exhibiting to me his/her competent evidence of identity by way of
__________________ issued at ______________ on __________________.

Doc. No. _____;

Page No. _____;

Book No. _____;

Series of 2016.
REPUBLIC OF THE PHILIPPINES)
Pasig City ) S.S.
x----------------------------x

AFFIDAVIT OF LOSS

I, NELY A. SALVADOR, of legal age, Filipino, married and a resident of No. 30-A J. Ramos St.,
Ibayo-Tipas, taguig City, after having been duly sworn to in accordance with law, depose and
state THAT:
1. I pawned a lady’s ring, earring pair and a pendant at Cebuana Lhullier Pasig last June 21, 2016
evidenced by pawn receipt number 10921SG032665, 10921SG032666 and 10921SG032667
respectively;

2. Sometime on September 30, 2016, said pawn receipts was misplaced and got lost;

3. Efforts were exerted to locate said pawn receipts, but in spite of diligent search, it could not
be found and the same is now beyond recovery;

4. Said pawn receipts has not been sold or transferred to another person;

5. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing and to
support my application for the re-issuance of another pawn receipt, in lieu of the one that was
lost;

IN WITNESS WHEREOF, I have hereunto set my hand this ___________________ in Pasig City,
Metro Manila, Philippines.

NELY A. SALVADOR
Affiant
SSS ID No. _____________

SUBCRIBED AND SWORN TO before me this ___________________ in _________________,

Philippines, affiant exhibiting to me his/her competent evidence of identity by way of
__________________ issued at ______________ on __________________.

Doc. No. _____;

Page No. _____;

Book No. _____;

Series of 2016.