REPUBLIC OF THE PHILIPPINES ] S.S. MANILA CITY

AFFIDAVIT OF OWNERSHIP AND LOSS WITH UNDERTAKING

I, _________________________________________________ of legal age,Filipino citizen and a resident of ______________________________________________________ withtelephone number _________________ and with officeaddress at_______________________________________________ and office number ______________________ after being sworn in accordance with law do herebydepose 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

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;

9

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:

Photocopy of passport Photocopy of driver’s license

Photocopy of postal ID

Proof of ownership of the unit (e.g. receipt of purchase, owner’s certificate,

barcode sticker from the box)

]

IMEI (International Mobile Equipment Identification)

OR Any two (2) of the following:

Photocopy of company ID/ school ID Photocopy of TIN/SSS/GSIS ID

AFFIANT

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

SUBSCRIBED AND SWORN TO BEFORE ME on this _________ day of ___________________, 20___, affiant has exhibited to me his/her Community Tax Certificate No. __________________ issued on ___________________ at _____________________.

ADMINISTERING OFFICER