Republic of the Philippines

Province of Cagayan
Municipality of ___________
x--------------------

)
) S.S.
)
- - - -x

Affidavit of Loss of Firearm

I, ______________ Filipino, of legal age, married, and with residence at
Leron, Buguey, Cagayan, Philippines, after being duly sworn to in
accordance with law, hereby depose and state:
1. That I am the grandson of the late _____________ who died in
_______________ as evidenced by his Death Certificate, which is
attached as Annex A hereof;
2. That my grandfather, the late _____________, once owned a firearm
with the following description:
KIND
MAKE
CALIBER
3. That the said firearm got lost upon his untimely demise;
4. That despite diligent search and efforts to locate the firearm, I
could not find the same such that I now have reasons to believe that
it is now lost and cant be recover; 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 of
________ 20___ at Buguey, Cagayan, Philippines.
_______________
AFFIANT
SUBSCRIBED AND SWORN TO BEFORE ME, a notary public this ___th
day of ____________ 20___. Affiant personally came and appeared with his
Drivers License _________________ issued by the Land Transportation Office
on ___________ at Aparri, Cagayan, bearing his photograph and signature,
known to me as the same person who personally signed the foregoing
instrument before me and avowed under penalty of law to the whole truth
of the contents of said instrument.