REPUBLIC OF THE PHILIPPINES] S.S.

QUEZONT CITY

AFFIDAVIT OF OWNERSHIP AND LOSS WITH UNDERTAKING

I, MARK DRANREB O. ROYO of legal age, Filipino citizen and a resident of 14 Center Village,
Paciano Rizal, Calamba City, Laguna, Philippines with cellphone number 09178833732 and with office
address at #9 West Road, Light Industry & Science Park 1 (LISP 1), Cabuyao, Laguna and office number
(02) 8857281 to 82 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)
IPHONE 6+ 64GB GRAT 3 5 6 9 9 5 0 6 1 2 6 3 1 1 8

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;

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 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.

MARK DRANREB O. ROYO

AFFIANT
 Signature over printed name

SUBSCRIBED AND SWORN TO BEFORE ME on this 11th day of May 2018, affiant has
exhibited to me his Driver’s License No. __________________ issued on _______________________
at ________________________.

ATTY. EMELITA C. BASAN

NOTARY PUBLIC
UNTIL DECEMBER 31, 2018
COMMISSION NO. 2016-23
ROLL NO. 65707
Doc. No. _______; PTR. NO. 3318878/4-JANUARY-2018
Page No. _______; IBP NO. 1062894/18-NOVEMBER-2017
Book No. ________ Block 9, Lot 8, Rosewood Homes
Series of 2018 Brgy. Tagapo, City of Sta. Rosa, Laguna