REPUBLIC OF THE PHILIPPINES)

CITY OF TACLOBAN ) S.S.

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AFFIDAVIT OF LOSS

I, bbbbbbbbbbbbbbbbbbbbbbbbbbbb, married, of legal age, Filipino, and a resident of

vvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvv after having been duly sworn to in
accordance with law, depose and state THAT:

1. That I am a holder of a Unified Multi-Purpose Identification (UMID) Card issued by the

Government Service Insurance System or GSIS;

2. That I used to place the said UMID Card in my wallet;

3. That sometime on December 2016, I discovered that said UMID Card was no longer in
my wallet where I usually place it;

4. That I have exhausted all efforts to locate the same, but to no avail;

5. That the said documents were neither transferred to other person/entity/financial

institutions for any consideration nor encumbered to guarantee financial obligations
with any financial institution;

6. That said UMID Card was not confiscated by the authorities or the government by
reason of any violation of Office rules and regulations;

7. That I am executing this Affidavit to attest to the truth of the foregoing and to
comply with the requirements of the GSIS for the reconstitution of said
card/document.

IN WITNESS WHEREOF, I have hereunto set my hand this 22nd day of January 2018 in
Tacloban City, Philippines.

Affiant

SUBCRIBED AND SWORN TO before me this 22nd day of January 2018 in Tacloban
City, Philippines, affiant exhibiting to me his/her competent evidence of identity indicated
below her name.