Republic of the Philippines )

Jabonga, Agusan del Norte) S.S.

x-----------------------------------x

AFFIDAVIT OF LOSS

I, IRENE A. ROA, 48 years old, Filipino, married, and a resident of Purok 3-B,
Barangay Baleguian, Jabonga, Agusan del Norte, Philippines, after having been sworn
to in accordance with law, do hereby depose and state:

1. That I am a holder of a Land Bank of the Philippines (LBP) Cabadbaran City

Branch ATM Card ---as a 4Ps beneficiary--- with Account Number 6031-3100-3150-
0085-273;

2. That the said LBP ATM Card was recently issued to me early this year (2019);

3. That my common-law husband, REY P. REAMBONANZA, 46 years old, and a

resident of Sitio Mangganab, Purok 4, Barangay Bangonay, Jabonga, Agusan del
Norte, took the said LBP ATM Card together with other valuable personal documents,
e.g., Voters ID, Phil Health ID, 4Ps ID, contained in my wallet without my permission
last October 23, 2019;

4. That he took these personal documents immediately after he evaded arrest by

the Jabonga police personnel on the aforesaid date, after I reported to the authorities
the physical violence/battering and rape he inflicted upon my person the day before,
October 22, 2019;

5. That I executed herein affidavit to attest to the truth of the foregoing facts
above-stated in order that a new Land Bank of the Philippines (LBP) Cabadbaran City
Branch ATM Card, as a 4Ps beneficiary, shall be issued to me to replace the one that
was lost and for no other purpose contrary to law.

IN WITNESS WHEREOF, I hereunto affixed my signature this 8th day of

November 2019 at Jabonga, Agusan del Norte, Philippines.

IRENE A. ROA
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, this 8th day of November 2019
at Jabonga, Agusan del Norte, Philippines. I hereby certify that I personally examined
the affiant and I am convinced that he personally executed this Affidavit freely and
voluntarily and he understood the same.

ATTY. GENE ESTEBAN S. PRISCO, JR.

Notary Public
Until December 31, 2022
PTR No. 7488410 – 09 -13 - 19
Doc. No. _____ IBP No. 088695 – 06-07-19
Page No. _____ Roll No. 72316
Book No. _____ MCLE Compliance:
(Exempted, pursuant to MCLE
Series of 2019. Governing Board Order No. 1, s. 2008)