REPUBLIC OF

QUEZONT CITY

THE

PHILIPPINES]

S.S.

AFFIDAVIT OF OWNERSHIP AND LOSS WITH UNDERTAKING

I, _________Renmar John A. Abagat_______ of legal age, Filipino citizen and a resident of #48
Adelina St. San Carlos Binangonan Rizal 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)
3

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
abovementioned carriers liable for whatever claims, loss or damages and party may institute by
reason of NTCs 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 drivers license

Proof of ownership (
the box)

receipt of purchase,

In the absence of any proof of ownership:

_______________
Additional Information:

Photocopy of company ID/school ID

Photocopy of TIN/SSS/GSIS ID
Photocopy of postal ID
owners certificate, x

barcode/sticker from

Police Report

Others / Pls. specify

Sex:

Lost Lost / Misplaced

Robbery Stolen (Theft / Robbery / Hold-up)

Age:

x M
below 18
40-49

F
x 18-29
50-59

30-39
60 above

Place of incident: ___Tayuman Binangonan Rizal______

Date
: ____June 11, 2015__________________
Nigthtime
5.

Daytime

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