(Affidavit of Loss Pawnshop Ticket)

Republic of the Philippines)

Province of ____________________)S.S.

City/Municipality of _____________)

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

AFFIDAVIT OF LOSS

I, _____________, Filipino, of legal age, (single / married / widow), and a resident of _____________,
Philippines, after being duly sworn in accordance with law, depose and state:

That sometime on _____________, I pawned my _____________ with Agencia _____________ located

at _____________ and for which I was issued Pawn Tickets / Receipt No. _____________.

That sometime on _____________, my wallet that contains the said Pawn Ticket was misplaced and got
lost.

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

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing facts.

IN WITNESS WHEREOF, I have hereunto set my hand this _____________ at _____________, Philippines.

Affiant
(JURAT))