R epublic of the P hilippines

D epartment of E ducation
REGION XII
DIVISION OF GENERAL SANTOS CITY

GSIS LOAN BORROWER'S

DECLARATIONS/ MANIFESTATIONS

I solemnly declare/ manifest:

That I, _________________________ _________, __________________________

(Name of Employee) (Position)

of __________________________, in this Division.

(Name of School)

Has no pending administrative charges/ cases in the DepEd and in any administrative
tribunals;
Has no pending criminal charges/ cases in any criminal courts within the outside of the
Philippines;
That I am liable for deception, dishonesty and misrepresentation in the event that the
above information is not true and correct.
That the DepEd's authorized Indorsing Official for my loans with the Government
Service Insurance System (GSIS) is free from any liability/ies arising from the aforesaid
transaction with falsified information/s.
This Declaration/ Manifestation is made to support the certificate signed by the
DepEd's authorized indorsing official in the GSIS loan application forms that I have no pending
administrative and/or criminal charge/s.

Done this _______ day of _____ in the city of General Santos,

Philippines.

_________________
Teacher - Borrower
(Printed Name Over Signature)

SIGNED IN THE PRESENCE OF

______________________ ______________________
School Head/ Principal Teacher
(Printed Name Over Signature) (Printed Name Over Signature)