Republic of the Philippines)
Province of Masbate…….) S. s
Municipality of Cataingan..)
x---------------------------------x
AFFIDAVIT OF LOSS
I, _____________________________________, ______ years old, Filipino,
and a resident of ________________________________________, Masbate, after
having been duly sworn to in accordance with the law under oath, hereby depose and
say, THAT:
1. I am ________________________________________________ , and a
holder of the following documents, to wit:






2.
PAWNTICKET NO : 00650823
LOAN DATE : SEPTEMBER 19, 2020
MATURITY DATE : OCTOBER 19, 2020
AMOUNT : 4,350
KARAT :
GRAMAS :
That
sometime
on
_____________________________ at
______________________, Masbate, and while under my possession, care
and custody, aforementioned paper, article, document or certificate, was;
 Lost
Embezzled
Mutilated
3. That diligent effort were exerted to locate, retrieve, repossess, restore and
save the same proved futile, ineffectual, unsuccessful and fruitless;
4. I executed this affidavit to attest to the truth of the foregoing statements.
IN WITNESS WHEREOFF, I have hereunto set my hand this _______ day
of ___________________, 20___ at _____________________, Masbate,
Philippines.
_____________________________
Affiant
SUBSCRIBED AND SWORN to before me this ____ day of
__________________ at Cataingan, Masbate, Philippines. Affiant exhibiting to me
his/her ____________________ bearing number ____________________________
as competent proof of his/her identity.