Republic of the Philippines )

) S.S.

AFFIDAVIT

I, ________________________________________, Filipino, of legal age, with residence address

at ____________________________________________________________________, after
having been sworn to in accordance with law, hereby depose and state that:

1. On or about _______________________, I have been the end-user/holder-in-fact of PLDT

landline and/or with data subscription under telephone number
_______________________ with account number _______________________ located
at _______________________________________________________________;

2. I assumed the use of the PLDT telephone and/or data service due to
________________________________________________________________________
as I have been consistently paying the above subscription from assumption to date;

3. I attest that the statement I provided under clause number two is based on my personal
knowledge and/or supported by existing documents or available records;

4. Thus, I hereby request the reassignment/transfer of the existing PLDT subscription under
my name and I hereby acknowledge and undertake to be responsible for the settlement
of all billed and unbilled usage prior to the effectivity of this request, on top of the usual
charges of the subscription for PLDT Services;

5. I hold PLDT Inc. harmless and indemnified against all claims, lawsuits, demands, causes of
action, liability, loss, damage and or injury arising out of the execution of this request;

6. PLDT Inc. reserves the right to revert the Telephone and/or Data service to the previous
customer on record in the event that the latter claims for such.

7. This affidavit is being executed to attest to the truthfulness of the foregoing and for
whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this _______________ in the City of
_______________, Philippines.

Affiant
 SUBSCRIBED AND SWORN to before me, a Notary Public and in the City of __________,
this ___________day of ___________20__, ____________________ personally appeared, with
____________________ the same person who executed and voluntarily signed the foregoing
affidavit which he acknowledged before me as his free and voluntary act and deed.

Witness my hand and Notarial Seal on the date and place first above written.

NOTARY PUBLIC

DOC. NO. ____;

PAGE NO. ____;
BOOK NO. ____;
Series of 20__.