REPUBLIC OF THE PHILIPPINES)

) 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. I pawned my wedding ring with Cebuana Pawnshop located at Mabalacat, Pampanga,

for and in consideration in the sum of five thousand five hundred sixty eight (PHP
5,568.00) which I was issued a pawn ticket/ receipt.

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

3. Last June, 2018 at around 07:30 pm, I lost the said pawn ticket/ receipt when I
discovered that it was no longer in my wallet where I used to place it;

4. Despite diligent search and efforts to locate the said pawn ticket/ receipt, I could not
find the same such that I believe that they are now lost beyond recovery;

5. 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

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 2018.