Loss Report – LICENSE TO CARRY OR FIREARM I.D. CARD

I, , report the loss of my (License to Carry Firearms) (Firearm Identification Card). I do this under the penalties of perjury (M.G.L. Ch. 268 Sec. 1) and have reported same to the Commissioner of Public Safety. I understand that no other license or card will be issued prior to an investigation of this reported loss, and shall report forthwith the recovery of said license and turn same in if a duplicate was issued.

On this date, I report this loss as fact due to the following circumstances. *

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Date of Loss: *

Reported To: *

Number of card or license *

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Date of Issue: *

Date: of Expiration: *

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

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Telephone: *

Social Security Number: *

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Date of Birth: *

Place of Birth: *

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Name of Mother (maiden) *

Father *

Any false statement or misrepresentation may be cause for permanent revocation of license.

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Date: *

Witness: *

This form must be accompanied by a Police Report from the jurisdiction in which the license was lost or stolen.