REPUBLIC OF THE PHILIPPINES)

PROVINCE OF LA UNION ) Sc.

MUNICIPALITY OF TUBAO )
x-------------------------x

AFFIDAVIT OF CHANGE ADDRESS

I, LENARD SUAN FANGON, of legal age, married, Filipino and a resident of
PUROK 1, LINAPEW, TUBAO, LA UNION, 2509, after having been duly sworn to
in accordance with law, do hereby declare and say that:

1. That I am a holder of the following firearm/s described below:

KIND MAKE/MODEL CALIBE SERIAL NO

R
PISTOL GLOCK 27 .40 ABNA766

2. That the aforesaid firearm/s was/ were not used in a crime or used as an
evidence before any court proceedings;

3. That I am requesting for the Change of my address in the FEO FIMS

Records from NAMONITAN, STO. TOMAS, LA UNION to PUROK 1,
LINAPEW, TUBAO, LA UNION, 2509 for me to proceed on the
processing of my firearm licenses;

4. That I transferred residence on 2020 to my new residence address for the

reason that married with person residing in that address;

5. That my firearm is currently kept at PUROK 1, LINAPEW, TUBAO, LA

UNION, 2509 with PTCFOR since 2020;

6. That I hereby execute this affidavit in support of my application/ request

for the change of my previous address to my new address in the FEO FIMS
Records and for other legal purpose this may best serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 25th day of

August 2022 at Tubao, La Union, Philippines.

LENARD SUAN FANGON

Affiant
Non-Prof DL No. A04-11-001996

SUBSCRIBED AND SWORN to before me this 25th day of August 2022 at

Tubao, La Union by the affiant appearing personally and who is known to me to be the
same person who executed this affidavit.

ATTY. JOONEE RANDYL E. RIVERA

Notary Public until December 31, 2022
Doc. No.: 89; Aspiras Highway, Francia Sur, Tubao, La Union
Page No.: 18; Roll No. 61766, TIN 929-347-628
Book No.: XXXIX; PTR No. 6677008, 01-03-22, Tubao, LU
Series of 2022. IBP Life Member No. 012553; 01-02-14, SFLU
Commission No. ANC-2020-70
MCLE No. VII-0004258, 07/21/21
 DATE: August 25, 2022

APPLICATION FORM FOR CHANGE OF ADDRESS:

(Reference: FLRRB Resolution No. 2020-700 “RECOMMENDING THE ADHERENCE

TO PROPER PROCESS AND APPROPRIATE FINE RELATIVE TO CHANGE OF
ADDRESS OF FIREARMS IN THE FIREARMS INFORMATION MANAGEMENT
SYSTEM”)

Requesting Person or Representative: FANGON, LENARD SUAN

Name of License (Individual or Juridical): FANGON, LENARD SUAN
Office Address/Business Address: PUROK 1, LINAPEW, TUBAO, LA UNION, 2509

DEATAIL OF ALTERATION/CORRECTION BEING REQUESTED:

From: NAMONITAN, STO. TOMAS, LA UNION
To: PUROK 1, LINAPEW, TUBAO, LA UNION, 2509
Contact Number: 09277140581
Firearm Details: (Attached additional page if necessary)

NO. KIND MAKE CALIBER STATUS SERIAL NUMBER

PISTOL GLOCK 27 .40 ABNA766

Documentary Requirements: (Please Check)

___ 1. Change of Address Form

___ 2. Notarized Affidavit of Undertaking of Change Address (state the date of
transfer)
___ 3. Photocopy of Proof of Billing (New Address)/ Barangay Clearance/Certificate
(New Address)
___ 4. Photocopy of LTOPF, Firearm Registrations and Valid ID’s
___ 5. Copy of Permit to Transport (PTT) of firearms and/or Permit to Carry Firearms
Outside of Residence (PTCFOR) during the time of transfer if there is.
___ 6. Special Power of Attorney if thru Representative

LENARD S. FANGON __________________________

Signature of Applicant over Printed Name Receiver