REPUBLIC OF THE PHILIPPINES] S.S.

QUEZONT CITY AFFIDAVIT OF OWNERSHIP AND LOSS WITH UNDERTAKING I, _________________________________________ of legal age, Filipino citizen and a resident of ________________________________________________________________________ with telephone number_________________ and with office address at ___________________________________________ and office number ______________________ after being sworn in accordance with law do hereby depose and say: 1. That I am requesting all CMTS carriers to block the GSM handset that was lost in my possession as owner thereof/stolen from me by an un identified person/s with particulars as follows: Make / Model / Type International Mobile Equipment Identification (IMEI)

2.

That I am also requesting ________________ to block the Subscriber Identity Module (SIM) card/cell phone number that was contained in the lost/stolen cell phone mentioned above; 9

3.

That I hereby undertake to hold free from any responsibility o r shall not hold NTC and the abovementioned carriers liable for whatever claims, loss or damages and party may institute by reason of NTCs action to permanently block the aforementioned unit from usage; That in support of this request and as proof of my ownership of said cell phone unit, I attached hereto the following documents, after making the original available for comparison; Any one (1) of the following: Photocopy of passport Photocopy of drivers license Proof of ownership ( receipt of purchase, OR Any two (2) of the following: Photocopy of company ID/school ID Photocopy of TIN/SSS/GSIS ID Photocopy of postal ID owners certificate, Police Report Sex: Age: barcode/sticker from the box)

4.

In the absence of any proof of ownership: Additional Information: ___ Lost / Misplaced ___ Stolen (Theft / Robbery / Hold-up)

Others / Pls. specify _______________ M F below 18 40-49 18-29 50-59 30-39 60 above

Place of incident: _________________________________ Date : _________________________________ Nigthtime 5. Daytime

That I am executing this affidavit of ownership and loss with undertaking to attest to the veracity and truthfulness of the foregoing declaration and to be used for whatever legal intent and purposes the same may thus serve.

FURTHER AFFIANT SAYETH NONE. _____________________________________ AFFIANT Signature over printed name SUBSCRIBED AND SWORN TO BEFORE ME on this ____ day of _______________ 2009, affiant has exhibited to me his/her Community Tax Certificate No. ___________________ issued on _______________________ at ________________________.

ADMINISTERING OFFICER