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Republic of the Philippines )

_____________________
)S.S.
_____________________
)
x - - - - - - - - - - - - - - - - - - - - -x
AFFIDAVIT OF LOSS
I, ___________________________, of legal age, Filipino, and a resident of
___________________________________, after having been duly sworn to in
accordance with law, hereby depose and say:
1. That I am the same person executing this affidavit;
2. That I am an owner of an Automated Teller Machine (ATM) Card issued by
the Government Service Insurance System (GSIS);
3. That on _________________, I went to the ______________________
bringing with me my pouch containing the above-mentioned ATM Card.
Moments later, I noticed that my ATM Card was no longer in my pouch,
hence I exerted my best effort to locate the said ATM Card, but all my efforts
were in vain;
4. That the said GSIS ATM Card is now considered lost and beyond recovery;
5. That I am executing this affidavit to attest to the truth of the foregoing for
whatever lawful purpose that it may serve and to notify and request the
Government Service Insurance System regarding such loss and for the
issuance of a new ATM Card in place of the lost one;

IN WITNESS WHEREOF, I have hereunto set my hand this ___ day of


______________, 2014 at _____________________________.

____________________________
Affiant

SUBSCRIBED AND SWORN to before me this ___ day of ______________,


2014 at ____________________________.

Doc No. _____


Page No. _____
Book No . _____
Series of 2014.

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