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