SELF-DECLARATION OF SURVIVING SPOUSE

(on Non-Marriage I Non-Cohabitation)

GSIS Form No. 01222018-SDSS-REV O

I JUANITO B. CABALLERO), of legal age, Filipino, and a resident of

BUENAVISTA, CARCAR CITY, CEBU hereby state as follows:

I have not remarried, cohabitated with another person, or otherwise engaged in a

common-law relationship since the death of my spouse, NICANORA G. CABALLERO.
I acknowledge that, if granted, my entitlement to survivorship benefit from the GSIS will
be automatically and permanently terminated the moment I re-marry, co-habit with any
person, or engage in a common-law relationship.

I undertake to reimburse/return to the GSIS, without need of demand or judicial action,

all survivorship benefits that I may unduly receive after my entitlement thereto is
terminated as stated above.
I further acknowledge that any misrepresentation, concealment and inaccurate and
untruthful statement on my part shall be a ground for criminal and civil action against
me.

Name and Signature of Legal Surviving Spouse

JUNE 18, 2022

Date