Republic of the Philippines)

City of Makati ) S.S.

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

AFFIDAVIT OF LOSS OF GSIS POLICY

I, MARIA C. DELA CRUZ, of legal age, married, Filipino citizen, and a resident
of 3333 HormigaStreet, Valenzuela, Makati City, after being duly sworn to in
accordance with law, depose and state that:

(1) I am a government employee and a member of the Government

Service Insurance System (GSIS);

(2) Being a member of the GSIS, I was issued a GSIS Policy Contract under CM-
473173;

(3) I used to keep the said Policy Contract in our home;

(4) Recently, I search for the said Policy Contract because my policy already
matured but I could no longer find the same;

(5) Said document must have been lost when I transferred residence from Paco,
Manila to Poblacion, Makati City;

(6) Despite diligent search and effort to locate the said Policy Contract, the same
could not be found such that I now consider it lost beyond recovery;

(7) As such, I am executing this Affidavit of Loss to attest to the foregoing and for
any legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 8th day of June
2018 in Makati City.

MARIA C. DELA CRUZ

Affiant

SUBSCRIBED AND SWORNto before me this 8th day of June 2018 in the City of
Makati, Philippines, affiant exhibited to me her Unified Multi-Purpose ID CRN-111-222-
3333-1 as valid proof of identity.

Doc. No. _____

Page No. _____
Book No. _____
Series of 2018.