REPUBLIC OF THE PHILIPPINES)

CITY/MUNICIPALITY OF _____ ) 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. Sometime on ______________, I pawned my _________ with Tambunting Pawnshop located at _____________________ and for which I was issued Pawn Ticket/Receipt No. _________;

2. I kept the said pawn ticket in my wallet for safekeeping but unfortunately my wallet got lost;

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

4. 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 ____ day of ___________ 20____ in ____________, _____________, Philippines.

___________________________________

Affiant

GSIS ID No. _____________

SUBSCRIBED AND SWORN to before me, this ____ day of __________ 20____, in the City of __________________, by ___________________ with Passport No.________________ issued on __________________ at _____________.

Notary Public

Doc. No. ______;

Page No. ______;

Book No. ______;

Series of ______;