REPUBLIC OF THE PHILIPPINES)

PROVINCE OF LEYTE . . . . . . . . . )S.S.

MUNICIPALITY OF _________ )
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AFFIDAVIT OF LOSS

I, ______________, of legal age, Filipino, and resident of

____________, Leyte, after having been sworn to in accordance
with law, do hereby depose and say:

1. That I have pawned one (1) pc. 1 YG Necklace Def

(2.3G; 18K) at RD PAWNSHOP, Palompon, Leyte in
the amount of P4,100.00;

2. That I was consequently issued a Pawn Ticket with

serial no. 03712406;

3. That said pawn ticket was lost and despite diligent

efforts exerted in looking for it, the same could no
longer be found and therefore considered it lost;

4. That I executed this affidavit to prove primarily the

foregoing facts as required of me by the said
pawnshop.

IN WITNESS WHEREOF, I have hereunto set my hand this

23rd day of November 2020, at Palompon, Leyte, Philippines.

___________________
(Affiant)
PIT ID:

SUBSCRIBED AND SWORN to before me this 23rd day of

November 2020, at Palompon, Leyte, Philippines.