REPUBLIC OF THE PHILIPPINES )

CITY OF DAVAO ) S.S.

X----------------------------------------------------X

AFFIDAVIT OF LOSS

I, -, Filipino, of legal age, and a resident of Davao City, Philippines, after

having duly sworn to in accordance with the law, hereby depose and say that:

1. Sometime on August 9, 2022, I pawned my - in the amount of

One Thousand Nine Hundred Pesos Only (Php 1,900.00), with
MLhuillier Philippines located at _____________________ and
for which I was issued Pawn Ticket/Receipt No. -;

2. I kept the said pawn ticket in my wallet for safekeeping but

unfortunately the described ticket above got lost;

3. Despite diligent search and efforts to locate the said pawn

ticket, I could not find the same such that I believe that they are
now lost beyond recovery;

4. As such, I am executing this affidavit to attest to the foregoing

facts and to enable me to secure a duplicate or substitute copy
of the ticket and/or redeem the above-described item which I
pawned.

IN WITNESS WHEREOF, I have hereunto set my hand this _________ in

the City of Davao, Philippines.

_________________________________
-
Affiant

SUBSCRIBED AND SWORN to before me this __________ in the City of Davao,

Philippines, affiant having exhibited to me her ________________ with ID
Number _______________ issued on ____________ at _____________