Republic of the Philippines

AFFIDAVIT OF LOSS

I, __________________________________________, Filipino, of legal age,

single/married to ___________________________________________, and residing at
_____________________________________________________________, Cebu,
having been sworn in accordance with the law, hereby depose and state:

1. I contracted a loan in the principal amount of Pesos:

____________________________________________________, (P ) with
the Sugbuanon Rural Bank, Inc.- Mandaue branch (the BANK).
2. As collateral for such loan, I pledged some of my jewelries.
3. As evidence of said pledge, I signed and was given the original of a PLEDGE
LOAN RELEASE VOUCHER (the VOUCHER) which was to be
surrendered to the BANK to redeem the jewelries pledged upon full payment
of the loan.
4. The particulars of the VOUCHER are as follows:
Voucher No. :
Amount of Loan :
Date Issued :

5. However, last _____________________________________________, I

discovered that the said VOUCHER was missing.
6. Diligent efforts to recover the same have proven futile.
7. I am executing this Affidavit in order to claim the jewelries I pledged with the
BANK and for such other purposes that this will serve.
8. That I hereby agree to hold the BANK harmless and to indemnify it for any
loss, damage or other expenses that it may sustain or incur by reason of the
release of the jewelries to me. In this case, the BANK is authorized to debit
my account for such losses or expenses or I hereby undertake to refund the
bank for any loss or damage resulting therefrom upon written demand by the
bank.

IN WITNESS WHEREOF, I have hereunto affixed my signature this __________

day of ______________________________, at
_____________________________________________, Cebu, Philippines.

________________________
Affiant

SUBSCRIBED AND SWORN to me before this _____________day of

______________________, at ________________________________________,
Cebu, Philippines, affiant exhibiting to me his/her Community Tax Certificate
No.___________________________, issued on _________________________,
at _____________________________________.

Doc. No. ________________;

Page No. ________________;
Book No. ________________;
Series of _________________;