Republic of the Philippines }

______________ } s.s.

AFFIDAVIT OF LOSS
Of Pawn Ticket

I, _______, of legal age, Filipino and a resident of _____, after having been duly sworn on
oath in accordance with law hereby depose and state that:

1. On ___, I pawned the following at ____ Pawnshop, ______, with the following details:

Pawn Ticket Number: 1) 6182419PMIC798768

Loan Date: 10/14/ 2019
Maturity Date: 11/14/2019
Expiry Date: 02/12/2020
Amount: P3,200.00
Definition of pawned item: 1 DEF EARRING PAIR PICA 21K 1.4 GRAMS

2. Sometime in January 2020, I realized that the said pawn ticket was no longer in my
possession;
3. I might have misplaced it at our house;
4. Despite diligent search and efforts to find the said pawn ticket/receipt, I could not find the
same such that I now believe that this is now lost and beyond recovery;
5. I am now executing this statement to attest to all the above facts.

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

__________________

Affiant

SUBSCRIBED AND SWORN to before me, a notary public in and for ___, affiant
appearing before me with his/ her competent evidence of identity ___, and presenting to me the
above document, and who signed the said document in my presence and sworn as to said document
that he/ she understood the contents thereof and that the same was his/ her free and voluntary act
and deed.

IN WITNESS WHEREOF, I have hereunto set my hand and affixed my notarial seal this
___ at ___.