Republic of the Philippines )

) S.S.

AFFIDAVIT OF LOSS
KNOW ALL MEN BY THESE PRESENTS:

I, _____, of legal age, Filipino, and a resident of _______ after having been
sworn in accordance with law, hereby deposes and states the following:

1. On ______ 2022, I pawned a _______ with _______ Pawnshop located at

__________, and for which I was issued a receipt, with the following details:

2. I misplaced the said receipt, and I can no longer find the receipt despite
diligent efforts;

3. I discovered that the said receipt is irretrievably lost and can no longer be
found;

4. I hereby execute this affidavit to attest to the truth of the foregoing. 

_________________

SUBSCRIBED AND SWORN TO before me this _________ in ______

Philippines, affiant exhibiting to me her ______