Republic of the Philippines

NATIONAL POLICE
COMMISSION
NATIONAL HEADQUARTERS PHILIPPINE NATIONAL POLICE
CIVIL SECURITY GROUP
Firearms and Explosives Office
Camp Crame, Quezon City

Write in all capital letters & mark (d)the BOX providedif needed

LOST FIREARM T&GGI/4G REQUEST FORN

Control No. Date ” ”
IIIFORMATlON€IFR €IUEET/NG ENTITY
raaxema I I I
First Namo

Q‹ialift er
fiompery /«vz»
ADDREA6 OF THE REARIt8 3LD5B .
F ¥J‹
Unit NO:/BId
.st«eoe»
cg•iwnispaar
CORTAGT xns.

FiREABlb/E. DA“TA ”
KIND MAKE/MODEL CALIBER SERIAL NUMBER

[To bef'fIIed out gy Veri]'ier/Togger Only)

TAGGED AS UI ON:

Verlfierj/Tagger:

[To be]fiIled out by Duty I & £ Section Personnel Onty)

CHECKLIST OF REQUIREMENTS

LOST FIREARM TAGGING REQUEST FORM ORIGINAL SPECIAL BANK RECEIPT (Amount: Php

ORIGINAL INVESTIGATION REPORT ORIGINAL CERTIFICATE OF POLICE BLOTTER

ORIGINAL AND NOTARIZED AFFIDAVIT OF LOSS DEATH CERTIFICATE (If Licensee is deceased)

SPECIAL POWER OF ATTY (SPA) IF REQUESTED THROUGHA REPRESENTATIVE

PTCFOR IF LOST OUTSIDE OF RESIDENCE

DATE FILED: REMARKS:

DATE OF INCIDENT:

DATE REPORTED:

Received By:

Signature of Applicant Duty I & E Section, EEMD