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Form No.11--Affidavit of Loss Pawnshop Ticket
(Affidavit of Loss Pawnshop Ticket)
Republic of the Philippines)
Province of ____________________)S.S.
City/Municipality of _____________)
x - - - - - - - - - - - - - - - x
AFFIDAVIT OF LOSS
I, _____________, Filipino, of legal age, (single / married / widow), and a resident of _____________, Philippines, after being duly sworn in accordance with law, depose and state:
That sometime on _____________, I pawned my _____________ with Agencia _____________ located at _____________ and for which I was issued Pawn Tickets / Receipt No. _____________.
That sometime on _____________, my wallet that contains the said Pawn Ticket was misplaced and got lost.
That despite diligent search and efforts to locate the said wallet and pawn ticket, I could not find the same such that I now believe that they are now lost beyond recovery.
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing facts.
IN WITNESS WHEREOF, I have hereunto set my hand this _____________ at _____________, Philippines.