Republic of the Philippines)

____________________ ) S.S.

Affidavit of Loss of Firearm

I, ________________, Filipino, of legal age, married, and with residence at

_____________________, after being duly sworn to in accordance with law, hereby
depose and state:

1. That I am the true and licensed owner of a one (1) unit __________ firearm with
the following description:

SERIAL NO.
KIND
MAKE
CALIBER

2. That sometime in ____________, I was surprised that my _________ as herein

described above was nowhere to be found in its hiding place;

3. That the said firearm might got lost or was misplaced together with its registration
or certificate documents when our house was submerged to flood due to typhoon,
the certainty of it being lost cannot be recalled;

4. That despite diligent search and efforts to locate the described firearm, I could not
find the same such that I now have reasons to believe that it is now lost and can’t
be recovered; and

5. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
and for whatever legal purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ___th day April 2021 at
______________, Philippines.

_____________________
Affiant

SUBSCRIBED AND SWORN TO before me, on _________________ at

___________, affiant exhibited to me his Driver’s License No. _______________________.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2021.