(Affidavit of Loss Firearm)

Republic of the Philippines)

Province of__________________) S.S.
City/Municipality of _____________)
x----------x

AFFIDAVIT OF LOSS
I, _____________, Filipino, of legal age, married and a resident of
_____________, Philippines, after being duly sworn in accordance with law,
depose and state:

That I am the true and licensed owner of a one (1) unit _____________
firearm with Serial No. _____________.

That on _____________, after having lunch at home, I was surprised to see

our gate open and when I went to close it, I discovered that my vehicle
parked at our garage was also opened;

I then discovered that my belt bag that I had left in the said vehicle was
gone and with it are the above-mentioned firearm, several rounds of
ammunition, the original copy of my License to carry the said firearm, some
identification cards, and other important documents;

That despite diligent search and efforts to locate said firearm, my belt bag
and its aforementioned contents, I could not find the same such that I now
believe that all the foregoing items were stolen and are now lost beyond
recovery.

As such, I am executing this Affidavit of Loss to attest to the truth of the

foregoing.

IN WITNESS WHEREOF, I have hereunto set my hand this _____________

at _____________, Philippines.

AFFIANT

(JURAT)
S=%SCRI%2 +1 S9;R1 (; %2;R2 M2, a notary public this ___th"ay of ____________ /<___. +8ant
personally ca!e an" appeare" #ith hisriver6s $icense _________________ issue" by the $an"
(ransportation ;8ceon ___________ at +parri, Cagayan, bearing his photograph an" signature,>no#n to !
e as the sa!e person #ho personally signe" the foregoinginstru!ent before !e an" avo#e" un"er penalty of
la# to the #

hole truthof the contents of sai" instru!ent.

REPUBLIC OF THE PHILIPPINES)
____________________ CITY ) S.S

AFFIDAVIT OF LOSS OF FIREARM

I,ROBERTO R. TAYAM, JR., of legal age, Filipino citizen, married, and with
residence at Purok 4, Bayabas St., Bo. Barretto, Olongapo 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 February 8, 2019, 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
andfor whatever legal purpose it may serve.

IN WITNESS THEREOF, I have hereunto set my hand this 9 th day of February, 2019 at
Olongapo City, Philippines.

ROBERTO R. TAYAM, JR.

Affiant
SUBSCRIBED AND SWORN TO before me on this ___ day of February, 2019 in
Olongapo City,affiant exhibiting to me his ________________ ID No. ____________
issued at _____________ on_______________.Doc No. ____;

Doc No. ____;

Page No. ____;
Book No. ____;
Series of 2019