REPUBLIC OF THE PHILIPPINES )

CITY OF DAVAO ) S.c.

AFFIDAVIT OF LOSS

I, TAHA, of legal age, Filipino, married and a resident of Isla Verde, Barangay 23-C,
Davao City, after having been duly sworn to in accordance with law, do hereby
depose and state that:

1. I am a member of the Government Service Insurance System during my

employment years;

2. I was issued with a Union Bank ATM for purposes of my transactions with
the GSIS;

3. Recently, I tried to look for my ATM card but could not be found;

4. Despite diligent search and efforts to locate, I could not find the same such
that I believe that it is now lost beyond recovery;

5. As such, I am executing this affidavit to attest to the foregoing facts and to

secure a new ATM Card.

IN WITNESS WHEREOF, I have hereunto set my hand this 29th day of January
2018 in Davao City, Philippines.

TAHA
Affiant

SUBSCRIBED AND SWORN TO before me this _______ day of January 2018 in Davao
City, Philippines, affiant exhibiting to me his valid proof of identification.

Doc. No. _____;

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