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QUEZONT CITY
THE
PHILIPPINES]
S.S.
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
Photocopy of passport
Photocopy of drivers license
Proof of ownership (
the box)
receipt of purchase,
barcode/sticker from
Police Report
Sex:
Age:
x M
below 18
40-49
F
x 18-29
50-59
30-39
60 above
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.
__________________________________
___
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