Republicof the Philippines )

City of Naga
) S. S.
AFFIDAVIT OF LOSS
I, NIO P. ADAYO, Filipino, of legal age, married and residing at Gubat, Tigaon,
Camarines Sur, after having been sworn to in accordance with law hereby depose and
state:
1.
That
I
am
a
holder
of
GSIS
Card
bearing
Number
______________________
/Common
Reference
Number
(CRN)
_______________________ issued by the Government Service Insurance
System;
2. That last August 1, 2015 , I put the said ID in the U-Box of my Motorcycle and
went to Camella Homes, Del Rosario, Naga City;
3. That after I arrived, I opened the U-Box to get the said ID but It was no longer
there;
4. That the same could not be found despite diligent efforts to locate it;
5. That I am executing this affidavit to certify the loss of the above mentioned ID
for the purpose of securing its replacement from the GSIS/UnionBank, Naga
City.
AFFIANT FURTHER SAYETH NAUGHT.
NIO P. ADAYO
Affiant
SUBSCRIBED AND SWORN to before methis ____ day of August, 2015 in Naga
City, with affiant exhibiting his Drivers License/LTO ID bearing no. E07-06 002420
issued on January 2015 at LTO-Naga City.