Affidavit of Loss Company Id Philippines

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					REPUBLIC OF THE PHILIPPINES] S.S.
QUEZONT CITY

                 AFFIDAVIT OF OWNERSHIP AND LOSS WITH UNDERTAKING

      I, _________________________________________ of legal age, Filipino citizen and a resident of
________________________________________________________________________ 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)


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.                                                                  r
     That I hereby undertake to hold free from any responsibility o shall not hold NTC and the above-
     mentioned carriers liable for whatever claims, loss or damages and 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:        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,       owner’s certificate,    barcode/sticker from the box)

     In the absence of any proof of ownership:       Police Report     Others / Pls. specify _______________

     Additional Information:                                    Sex:      M       F
     ___ Lost / Misplaced                                       Age:      below 18       18-29       30-39
     ___ Stolen (Theft / Robbery / Hold-up)                               40-49          50-59       60 above

     Place of incident: _________________________________
     Date            : _________________________________

        Nigthtime           Daytime

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 _______________ 2009, affiant
has exhibited to me his/her Community Tax Certificate No. ___________________ issued on
_______________________ at ________________________.



                                                                         ADMINISTERING OFFICER

				
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