ACCOUNTABILITY FORM

EMPLOYEE NAME

EMPLOYEE ID NUMBER

CLIENT’S NAME

POSITION

Other
Equipment/Item Model Number
Serial Number Remarks/Conditions

ACKNOWLEDGEMENT

 I received the equipment/tool/item mentioned above to be used exclusively for my assigned job.
 I fully understand that it is my sole responsibility to keep the above-mentioned equipment/tool/item in a
safe place while it’s in my custody.
 I am aware that if the said equipment/tool/item is lost, stolen, damaged or broken, it’s my duty to
immediately report the same to my supervisor and Employee Relations Officer.
 I understand that I may be charged, or be held responsible for the loss and/or damage of the above-
mentioned equipment/tool/item on account of my negligence, the amount of which shall depend on the
cost of loss and/or damage. For this purpose, I executed herein the attached Affidavit of Undertaking with
Authority to Deduct forming part of this Form.
 I also understand that once my employment ends, it is my responsibility to return all the above-mentioned
equipment/tool/item in its original condition as herein stated. Failure to do so, the company may withhold
my clearance process including my last pay, if any.

Received by: Noted By:

__________________________ ___________________________
Signature over Printed Name/ Date Signature over Printed Name/Date
Position Employee Relation Officer

Issued By: Approved By:

_____________ ____________________________
Technical Officer Technical Head Officer
 AFFIDAVIT OF UNDERTAKING
with AUTHORIZATION TO DEDUCT

I, ________________________________, of legal age, Filipino, with postal address at

___________________________________, Philippines, after having been duly sworn on oath, hereby
depose and say, THAT:

1. I am currently employed with Prime@ Technology Specialists, Incorporated (Prime) with office
address at 3rd Floor OAC Bldg. San Miguel Avenue Ortigas Center Pasig City;

2. I am deployed by Prime to Land Registration System Inc (LARES). as a ________________ with

office address at East Avenue Diliman Quezon City.

3. As a requirement of my employment, I agreed to sign an Accountability Form for the issuance

equipment/tool/item/mobile plan to be used exclusively for my work and shall never be used for
personal purposes which is not limited to movie viewing, access to social networking sites, games
and other applications requiring the use of data services;

4. I undertake that it is my responsibility for the loss and/or damage of the issued items stated in the
said Accountability Form and/or in the event in the event that the issued mobile plan exceeded its
monthly limit, I hereby authorize Prime@ Technology to deduct the cost of the same in my salary
and/or last pay, if there is any, otherwise I shall pay the same upon my clearance processing.

5. I am executing this document to attest to the truth of the foregoing and for whatever legal purpose
it may serve.

IN WITNESS WHEREOF, I have hereunto set my hands this _________________________ in

_____________________________, Philippines.

______________________________________
Affiant

SUBSCRIBED AND SWORN to before me this _____________________ in __________________,

Philippines, affiant having exhibited to me his/her __________________________________________
valid until __________________________.

Doc. No. ______;

Page No. ______;
Book No. ______;
Series of 2023.