REPUBLIC OF THE PHILIPPINES]

CITY OF SAN FERNANDO ] S.S.

AFFIDAVIT OF OWNERSHIP AND LOSS WITH UNDERTAKING

I, _________________________ of legal age, Filipino citizen and presently residing

at________________________________ with telephone number ________________, and with
office address at _______________________________ and office telephone no. ____________,
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 unidentified person(s) with
particulars as follows;

Make/Model International Mobile Equipment Identification (IMEI)

2. That I am also requesting (carrier) ___________________ to block the Subscriber

Identity Module (SIM) card/cellphone number that was contained in the lost/stolen
cellphone 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 damage 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 cellphone unit, I
attached hereto the following documents, after making the 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 Bar code/sticker from the box

Owner’s Certificate
In the absence of any proof of ownership: Police Report
Others pls. specify.

Additional Information: SEX: Male Female

Lost/Misplaced AGE: Below 18 18-29 30-39
Stolen (Theft/Robbery) 40-49 50-59 60 above
Place of Incident: ______________________________
Date : ______________________________

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 ______, 201__,

affiant has exhibited to me his/her Community Tax Certificate No.__________, issued on
_____________, at ______________________.

ADMINISTERING OFFICER