Republic of the Philippines)

Province of Masbate ) S.S.

City of Masbate )

AFFIDAVIT OF LOSS
I, Jojit C. Ramirez, of legal age, Filipino and a resident of Poblacion,
Baleno, Masbate, after having been duly sworn to in accordance with law, hereby
depose and say:

1. That I am the owner of a temporary E-Card issued by Government Service

Insurance System (GSIS);

2. That recently, I noticed that my E-Card was missing, efforts to locate in

vain, and for all intents and purposes considered lost or stolen;

3. That I wish to manifest that said card was not given or endorsed to
anybody but simply lost or stolen;

4. That I have executed this affidavit to attest to the truth of all the foregoing
and satisfy the inquiry or requirements of any person or office particularly
the GSIS and for other legal purpose.

IN WITNESS WHEREOF, I have hereunto set my hands this ______. day of

______, 2016 in the City of Masbate, Philippines.

__________________________
Affiant

JURAT

SUBSCRIBED AND SWORN to before me this _______day of

_________________________at _________________________________, affiant exhibited to me
his Community Tax Certificate No. ______________________ issued on ______________ at
_________________.

Notary Public

Doc. No. _________________;

Page No. _________________;
Book No. _________________;
Series of _________________;