Republic of the Philippines }

City of Calamba }s.s.

AFFIDAVIT OF LOSS

I, ______________________, of legal age, single/married, Filipino and with postal address at

__________________________, Calamba City, Laguna, after having been duly sworn to in accordance
with law do hereby depose and state:

1. That I have pawned a certain jewelry/gadget/appliance at ______________________;

2. That the pawnshop issued to me a certain receipt evidencing the above transaction;

3. That just recently, I discovered that the pawnshop receipt issued to me was missing
from my wallet/bag/filing cabinet;

4. That I exerted diligent efforts to find and locate my said pawnshop receipt but the same
could no longer be found and in all probability, might have been misplaced and
eventually lost;

5. That I executed this affidavit to attest to the truth of the foregoing and for whatever
legal purpose it may serve.

IN WITNESS WHEREOF, I hereunto affixed my signature this 16th day of April 2015, at
Calamba City.

___________________
Affiant
CEI:__________________

SUBSCRIBED AND SWORN to before me this 16th day of April 2015 at Calamba City,
affiant appeared and avows under penalty of law to the whole truth of the contents of this
affidavit.