REPUBLIC OF THE PHILIPPINES)

PROVINCE OF MANILA)s.s
MUNICIPALITY OF QUEZON CITY)

AFFIDAVIT OF LOSS FIRE ARM

I, MICHAEL DAIRO DAGDAG Filipino of legal age, married and with residence at Brgy Occidental Mindoro
after being duly sworn to in accordance with the law, hereby defense and state:

1. That I am the registered owner of a firearm with the following description:

Kind : PISTOL

Make : ARMSCOR

Caliber : 45

Serial No.:

2. That the said fire arms was mortgaged to De la Cruz,

3. That said firearm was lost by the mortgage during the period of the mortgage;
4. That despite diligent search and effort to locate the fire arms, the mortgage could not find
the same such that I now have reasons to believe that it is now lost and can’t 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 ___ 2o ____at
Sabalayan, Occidental Mindoro.
MICHAEL DAIRO DAGDAG
AFFIANT
SUBSCRIBED AND SWORN TO BEFORE ME, a Notary Public this ____th day of
_______20___ Affiant personally came and appeared with his Firearm License Card
_________ issued by the Philippines National Police an April 18, 2012 at Camp Crame,
Quezon City, 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 content of a said instrument.

Doc No. ____________________;

Page No ____________________;
Book No.____________________;
Series of 2018