REPUBLIC OF THE PHILIPPINES )

CITY OF MAKATI )

AFFIDAVIT OF LOSS

I, ROMEO AQUINO LACAMBRA, Filipino, ________, of legal age, resident of

Lacambra St. Libag Norte, Tuguegarao City, Philippines, after having been sworn in accordance
with law hereby depose and state that:

1. I am an owner of a caliber 40 smith&wesson pistol with serial no. NCE 5982 (firearm);

2. I always kept the said firearm together with the firearm license inside my car ;

3. On March 12, 2020, I dropped off my car in a Car Wash Station at _________________,
leaving the said firearm and my other personal belongings inside the car;

4. After the car wash was done, I immediately left the station without checking my
valuables;

5. Later that day, I find out that the case containing the aforementioned firearm and firearm
license is already missing;

6. Despite diligent efforts exerted, I could not locate or recover the said sling bag that
contains the firearm and the license, and to the best of my knowledge, the same is truly
lost.

7. The said firearm and license has not been confiscated by any officer of the law or the
issuing agency or office due to the violation of any law, statute, order, rule or regulation.

8. I am executing this affidavit to attest to the truth of the foregoing and for whatever
purposes it may serve.

IN TRUTH WHEREOF, I have hereunto signed my name below this _______________________at

Tuguegarao City, Philippines.

ROMEO AQUINO LACAMBRA

ID:
Affiant

SUBSCRIBED AND SWORN TO before me this __________________, at Tuguegarao

City, Cagayan, with affiant showing to me his ID as shown above with picture and signature as
competent evidence of identity.

Notary Public

Doc No. ________;

Page No. _______;
Book no. _______;
Series of 2020.