REPUBLIC OF THE PHILIPPINES)

Province of ___________
) S.S.
Municipality of________
)
x-----------------------x
AFFIDAVIT OF LOSS
I, ________________, Filipino, of legal age, and a resident _______________, , after
being duly sworn to in accordance with law, hereby depose and state:
That I am the same person executing this Affidavit;
That I am a government employee and a member of the Government Service Insurance
System (GSIS);
That being a member of the GSIS, I was issued by the GSIS a Policy Contract under CM
No. __________;
That I used to keep the above document inside our office at the ______________;
That it was only recently that I searched for the said Policy Contract because my policy
already matured but I could no longer find the same;
That despite diligent search and efforts to locate the Policy Contract, the same could not
be found such that I now consider it lost beyond recovery;
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing and
for any legal purpose it may serve.
IN WITNESS WHEREOF, I have hereunto set my hand this _______________ at
_________________.
_________________
Affiant
ID NO. __________
SUBSCRIBED AND
_______________________.

SWORN

WITNESS MY HAND AND SEAL.

to

before

me,

this

____________

at