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