Republic of the Philippines )

_____________)S.S.

AFFIDAVIT OF LEGAL/CERTIFIED GUARDIAN

OF MINOR DEPENDENT CHILDREN

I, _____________, of legal age, Filipino Citizen, with address at

_____________ and the following contact number _____________, after having
been duly swor n in accordance with law, hereby depose and state:

I am the legitimate mother and the legal guardian of _____________, a

child of the late _____________, who was a GSIS member / retiree, who died
on_____________ at _____________;

I hereby declare that the above-named child is the youngest of the

deceased; that she is not more than 18 years of age;

I am executing this affidavit to attest to the truth of the foregoing

statements in support of the application medical reimbursement on on my
Personal Accident Insurance Coverage and for whatever legal purpose it may
serve. I fully understand that any inaccurate and untruthful statement in this
affidavit shall render me criminally and civilly liable.

AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto signed my name this 29th day

of August, 2018 at _____________.

_____________
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, this September 10, 2018

a t _ _ _ _ _ _ _ _ _ _ _ _ _ . A f f i a n t e x h i b i t e d t o m e h e r V o t e r ’s I D
____________________________ at _____________ as competent proof of her
identity;

Doc. No. _____;

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