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;

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 and 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 ( receipt of purchase, owner’s certificate, barcode/sticker from the box)

In the absence of any proof of ownership: Police Report Others / Pls. specify _______________

Additional Information: Sex: M F

___ Lost / Misplaced Age: below 18 18-29 30-39
___ Stolen (Theft / Robbery / Hold-up) 40-49 50-59 60 above

Place of incident: _________________________________

Date : _________________________________

Nigthtime Daytime

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.

_____________________________________
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