REPUBLIC OF THE PHILIPPINES )

MUNICIPALITY OF ___________ ) S.S.

PROVINCE OF ISABELA )

AFFIDAVIT OF LOSS

I, _________________, of legal age, and resident of ____________, ___________, Isabela,

Philippines, after being duly sworn, depose and say:

That I am the holder of a PAWN TICKET bearing the pawn ticket number 6747, issued by
AUROTAM PAWNSHOP INC Cabagan Branch described as;

 Date Pawned : _________________

 Loan amount : 13,500
 Descriptions : 1 pc bracelet yellow gold and 1pc earring yellow gold
 Grams : 3.8 grams and 2.4 grams
 Karat : 18k and 21k

That on or about July 2023, my PAWN TICKET was lost when I accidentally dropped my ticket
while riding a tricycle going to the market;

That I inadvertently dropped my PAWN TICKET and its whereabouts cannot anymore be
ascertained despite due diligent search made and undertaken;

That I now desire and hereby request PAWN TICKET in lieu of the one lost, that I am willing to
surrender the lost ticket in the event that the same could be found or located;

That I bind myself to hold AUROTAM PAWNSHOP. INC. free and harmless from any loss or
damage that may arise or it may incur in connection with the issuance of new PAWN TICKET;

That each and all of the facts herein stated are true, and that I am willing to testify before any
court of justice to substantiate the truth of each and all of the above said facts.

IN WITNESS WHEREOF, the undersigned has signed there presents at Cabagan, Isabela, Philippines
on this August 3, 2023 at Cabagan, Isabela.

____________________
Affiant
PSA ID No. __________________

SUBSCRIBED AND SWORN to before me in _______________, Isabela, Philippines on August 3,

2023. The affiant exhibited to me her competent proof of identity.

Doc. No. ______;

Page No. ______;
Book No. _____;
Series of 2023.