Republic of the Philippines)

_____________________) S. S.

AFFIDAVIT OF UNDERTAKING

I, __________________________________, of legal age, Filipino and presently residing at

______________________________________________________________, after having been duly
sworn to an oath in accordance with the law, do hereby depose and say;

1. That, I am the registered firearm holder of the firearm/s describe below:

KIND MAKE CALIBER SERIAL NR EXPIRY DATE

2. That I and the aforesaid firearm/s was were not used nor involved in a crime or used as an
evidence before any court proceeding;

3. That I undertake to pay any penalty that may be imposed by the FEO License Revocation and
Restoration Board;

4. That I hereby execute this affidavit in support of my application for the tagging of the
aforementioned firearm/s as Unserviceable in the FEO FIMS Records and for other legal purpose
this may best serve.

IN WITNESS HEREOF, I have hereunto fixed my signature this ______________________ at

______________________.

____________________________
Affiant

SUBSCRIBED AND SWORN, to before me this ______________________ at

______________________ Philippines. Affiant exhibited to me his ____________________ issued on
__________________________ at ____________________ as his competent evidence of identity.

DOC. No._________
PAGE No._________
BOOK No._________
SERIES of 2023