REPUBLIC OF THE PHILIPPINES)

CITY OF SORSOGON
) S.c.
AFFIDAVIT OF LOSS

I, CAROLINA D. ESCUETA, of legal age, Filipino, single and a resident of Gubat,

Sorsogon, after having been duly sworn in accordance with law, hereby depose and
say;
1. That I am a retired Public School Teacher and a member of the
Government Service Insurance System;
2. That I was issued e-card by GSIS ;
3. That unfortunately said e-card was misplaced and could no longer be
located at our residence;
4. That in spite of my diligent efforts to locate said e-card, it proved to no
avail;
5. That I am executing this affidavit to attest to the foregoing facts and for the
purpose of reissuance in lieu of the lost one.
IN WITNESS WHEREOF, I have hereunto affixed my signature this 12 th day of
May, 2014 at Sorsogon City.

CAROLINA D. ESCUETA
SUBSCRIBED AND SWORN to before me this 12 th
Sorsogon City, affiant being personally known to me.

day of May 2015 at