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Sworn Affidavit & Proof of Loss Statement Page of 2 ‘THE PERSON COMPLETING TH'S DOCUMENT MUST BE THE AT&T ACCOUNT HOLDER AND MUST PROVIDE A COPY OF THEIR. VALID PHOTO 1, INSURANCE FRAUD IS A CRIME Account Holder information (for verification purposes only) PLEASE PRINT USING BLUE OR BLACK INK Pray Device Wetss Hunter ip 2) (eT 4-1 runam. Veronica” Morales conact numrer: CAE &7B-4BR to mena conse minder 48 939-5872 enatrscenr Veronica moretes he gmail.com stingacages: $12 1: Colvades Ave cry: ee ae zwcote: W723 _ ‘What device are you claiming? Device Type: VFFone [ILapap Tablet [lOther manteeneer: Alp |] le) | ||| (Cearph Poe Dl Teo) went (7 PIAlo Me] I i oe i (Barres actook Po, Tr¥Pad TQ, Pason Pai Ze Wr Fee HO a.) Date of Purchase: Place of Purchase: eta. is Memory SizeRAM (6 512Me, «G3, et2): ____ Operating System (Ex Windows 7,087.0) 3 ‘Additional information. Please be as specific as possible £ Dv Bunet, 512 GB SSD Herc Dive, 156 inch LCD Seren, nts Core” processor, et)? at eae i ie mormon nits Fat 18440" Comote Porro More Rev EOT:IMG7 or. a4 BSUSION IE —seccnsonneteriomnho SrsineanarCy moet Se

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