REPUBLIC OF THE PHILIPPINES)

____________________ CITY ) S.S

AFFIDAVIT OF LOSS OF FIREARM

I, ___________________, of legal age, Filipino citizen, married, and with residence at No. 27
Durian Street, Project 2, Quezon City, after having been sworn to in accordance with law, do
hereby depose and state that:

1. I am the true and licensed owner of one (1) firearm, which is particularly
described as:

Make: Caliber:
Kind: Serial No.:

A copy of my Firearm License Card is hereto attached as Annex “A”;

2. That on _____(date)_____, I was inspecting my personal belongings and was

surprised to find that the said firearm was missing from its case;

3. That despite diligent search and efforts to locate the abovementioned firearm, I
could no longer find the same, such that I now believe that it is lost beyond
recovery;

4. That I certify and confirm that the said firearm was neither confiscated nor
relinquished in favor of, any government entity, agency, or authority; and

5. That I am executing this Affidavit of Loss to attest to the truth of the foregoing and
for whatever legal purpose it may serve.

IN WITNESS THEREOF, I have hereunto set my hand this _____________ at ____________

City, Philippines.

______________________
Affiant

SUBSCRIBED AND SWORN TO before me on this ___ day of ________ in ________________ City,
affiant exhibiting to me his ________________ ID No. ____________ issued at _____________ on
_______________.

Doc No. ____;

Page No. ____;
Book No. ____;
Series of ______.