Republic of the Philippines…)

Province of Negros Oriental)

City of Tanjay……………………..)

AFFIDAVIT OF NO RE-MARRIAGE

I, ALICIA MANSO MIRA, of legal age, widow, Filipino and a resident of

Barangay Azagra, Tanjay City, Negros Oriental, Philippines, after having been
sworn to in accordance with law hereby depose and states that:

1. I am the widow of BENECIO C. MIRA, who died onJuly 20, 2018;

2. I hereby declare that since the death of my husband, BENECIO C. MIRA, I
have not remarried, cohabited with another person, have a live-in partner
or otherwise engage in a common-law relationship;
3. I acknowledge that, if granted, my entitlement to survivorship benefit from
GSIS will be automatically and permanently terminated the moment I
remarry, cohabit with any person/engage in common-law relationship;
4. As such, I am executing this affidavit to attest to the truth of the foregoing
facts in support of my application for survivorship benefit from the GSIS. I
fully understand that any inaccurate and untruthful statement in this
affidavit shall render me criminally and civilly liable.

IN WITNESS WHEREOF, I hereunto set my hand this ____________ at

Tanjay City, Negros Oriental, Philippines.

ALICIA MANSO MIRA

Affiant

SUBSCRIBED AND SWORN to before me, this ____________at Tanjay City,

Negros Oriental, Philippines, Affiant exhibited to me her OSCA ID No. 9513 issued
at Bais City OSCA Office on 07/11/13.

Doc. No.____;

Page No.____;

Book No.____;

Series of 2018.