REPUBLIC OF THE PHILIPPINES)

CITY/MUNICIPALITY OF _____ ) S.S.

x-------------------------------------x

AFFIDAVIT OF LOSS

I, ___________________, of legal age, Filipino, single and a resident

of _______________________________, after having been duly sworn to
in accordance with law, depose and state THAT:

1. Sometime on ______________, I pawned my _________ with

Tambunting Pawnshop 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
my wallet got lost;

3. Despite diligent search and efforts to locate the said wallet and 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 ____________, Philippines.

____________________
Affiant
GSIS ID No. _____________

SUBCRIBED AND SWORN TO before me

this ___________________ in _________________, Philippines, affiant
exhibiting to me his valid proof of identification.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2013.