REPUBLIC OF THE PHILIPPINES)

PROVINCE OF BULACAN S.S.

CITY OF MEYCAUYAN )

AFFIDAVIT OF LOSS

I, ____________________________, of legal age, married, Filipino and with

residence and post office address at _____________________________, after having been
sworn to in accordance with law, de hereby depose and say:

1. That I am a member of Government Service Insurance System (GSIS);

2. That as such I am the holder and in possession of the GSIS Card No.
____________________________;

3. That my said GSIS ID Card was lost and/or misplaced and all efforts to
locate the same proved futile, hence, it is now considered loss and is now beyond
recovery;

4. That I am executing this affidavit in order to make known to those

concerned the truth relative to the loss of my said GSIS ID Card in compliance with
the requirements of GSIS in connection with my request for issuance of its duplicate
and/or replacement and for whatever legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ___________ day of

____________ in the City of _____________________.

_________________________
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, this ___________ day of

__________________ in the City of ___________________ by ___________________ personally
known to me that she is the same person who personally assigned that she executed
the same.

Doc No. :_
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Series of 201_.