REPUBLIC OF THE PHILIPPINES] S.S.

QUEZON CITY ]

AFFIDAVIT OF OWNERSHIP AND LOSS WITH UNDERTAKING

I, ___________________________________________ of legal age, Filipino citizen and

presently residing at ___________________________________________________________
with telephone number ______________________ and with office address at
___________________________________________ and office telephone number
______________________ 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 unidentified person/s with particulars
as follows;

MAKE/MODEL 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;
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3. That I hereby undertake to hold free from any responsibility or shall not hold NTC and
the above-mentioned carriers liable for whatever claims, loss or damages any party may
institute by reason of NTC’s action to permanently block the aforementioned unit from
usage;

4. 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: OR Any two (2) of the following:
Photocopy of passport Photocopy of company ID/school ID
Photocopy of driver’s license Photocopy of TIN/SSS/GSIS ID
Photocopy of Postal ID
___ Proof of ownership of the unit (e.g. receipt of purchase, owner’s certificate, barcode
sticker from the box)
In the absence of any proof of ownership,

___ Police Report

5. 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.

Signature over printed name of affiant

SUBSCRIBED AND SWORN TO BEFORE ME on this _____ day of

____________________, 2002, affiant has exhibited to me his/her Community Tax Certificate
No. ___________________ issued on _________________ at _____________________.

ADMINISTERING OFFICER