REPUBLIC OF THE PHILIPPINES)

Pasig City
) S.S.
x----------------------------x

AFFIDAVIT OF LOSS
I, NELY A. SALVADOR, of legal age, Filipino, married and a resident of No. 30A J. Ramos St., Ibayo-Tipas, taguig City, after having been duly sworn to in
accordance with law, depose and state THAT:
1. I pawned a necklace, wedding ring and a ladys ring at Cebuana Lhullier
Pasig last June 20, 2016 evidenced by pawn receipt number
10921SG032644, 10921SG032645 and 10921SG032646 respectively;

2. Sometime on September 30, 2016, said pawn receipts was misplaced and
got lost;

3. Efforts were exerted to locate said pawn receipts, but in spite of diligent
search, it could not be found and the same is now beyond recovery;

4. Said pawn receipts has not been sold or transferred to another person;

5. As such, I am executing this Affidavit of Loss to attest to the truth of the

foregoing and to support my application for the re-issuance of another pawn
receipt, in lieu of the one that was lost;

IN WITNESS WHEREOF, I have hereunto set my hand this ___________________

in Pasig City, Metro Manila, Philippines.

NELY A. SALVADOR
Affiant
SSS ID No. _____________

SUBCRIBED AND SWORN TO before me this ___________________ in

_________________, Philippines, affiant exhibiting to me his/her competent
evidence of identity by way of __________________ issued at ______________ on
__________________.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2016.

REPUBLIC OF THE PHILIPPINES)

Pasig City
) S.S.
x----------------------------x

AFFIDAVIT OF LOSS
I, NELY A. SALVADOR, of legal age, Filipino, married and a resident of No. 30A J. Ramos St., Ibayo-Tipas, taguig City, after having been duly sworn to in
accordance with law, depose and state THAT:
1. I pawned a ladys ring, earring pair and a pendant at Cebuana Lhullier
Pasig last June 21, 2016 evidenced by pawn receipt number
10921SG032665, 10921SG032666 and 10921SG032667 respectively;

2. Sometime on September 30, 2016, said pawn receipts was misplaced and
got lost;

3. Efforts were exerted to locate said pawn receipts, but in spite of diligent
search, it could not be found and the same is now beyond recovery;

4. Said pawn receipts has not been sold or transferred to another person;

5. As such, I am executing this Affidavit of Loss to attest to the truth of the

foregoing and to support my application for the re-issuance of another pawn
receipt, in lieu of the one that was lost;

IN WITNESS WHEREOF, I have hereunto set my hand this ___________________

in Pasig City, Metro Manila, Philippines.

NELY A. SALVADOR
Affiant
SSS ID No. _____________

SUBCRIBED AND SWORN TO before me this ___________________ in

_________________, Philippines, affiant exhibiting to me his/her competent
evidence of identity by way of __________________ issued at ______________ on
__________________.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2016.