AFFIDAVIT OF LOSS

I, (name), Filipino, of legal age, married and with residence at

(current address), after being duly sworn in accordance with law,
depose and state:

1. That I am the licensed owner of a firearm with the

following description:

Kind : _______________
Make : _______________
Caliber : _______________
Serial No. : _______________;

2. That while I was preparing to leave the Philippines to work

in (place of work), I discovered that the said firearm got lost.

3. That despite diligent search and efforts to locate said

firearm, I could not find the same such that I now believe that it is lost
beyond recovery.

4. 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 _____________.

(NAME)

SUBSCRIBED and SWORN TO before me on the date and at the

place indicated below. The affiant exhibited to me his
__________________ as competent evidence of identity.

Signed this ______________at ________________.

WITNESS MY HAND AND SEAL.

Notary Public

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