REPUBLIC OF THE 

PHILIPPINES )
Municipality of Sergio Osmeňa, Sr. ) SS.

AFFIDAVIT OF SURVIVING SPOUSE

I, CONCEPCION MOAY EMPEYNADO, Filipino, of legal age, widow, and a

resident of Pob. Alto, Sergio Osmeňa, Sr.,Zamboanga del Norte under oath, state:

1. THAT I am the legitimate spouse of the late RODRIGO S. EMPEYNADO

having been married on April 9, 1988;
2. THAT my late husband , RODRIGO S. EMPEYNADO died intestate
November 15, 2020 at Dapitan City, Zamboanga del Norte;
3. THAT my late husband is a government employee, being a public school
teacher of Sergio Osmeňa National High School and a bona fide member of
the Government Service Insurance System (GSIS);
4. THAT I am executing this Affidavit to attest to the truth of the foregoing facts,
as a requirement for my death claim and survivorship claim before the
Government Service Insurance System (GSIS) and for whatever legal
purpose it may serve.

IN WITNESS WHEREOF, I hereunto affix my signature this ___________ at

Sergio Osmeňa, Sr.,Zamboanga del Norte, Philippines.

CONCEPCION MOAY EMPEYNADO

Affiant
Philhealth: 19-000627829-2

SUBSCRIBED AND SWORN to before me this _________________ at Sergio

Osmeňa, Sr.,Zamboanga del Norte, Philippines affiant exhibited to me her valid proof of
Identity as above-stated.

EARL RUSSELL S. PAULICAN

Notary Public
Until December 31, 2021
Roll No. 75530
PTR No. 2185126, 1/04/21, Dipolog City
TIN # 472-022-138
Notarial Commission No. SN: ZDN-DPL-042-2020

Doc No. ________;

Page No. _______ ;
Book No. _______;
Series of 2021.