AFFIDAVIT OF LOSS

REPUBLIC OF THE PHILIPPINES)

Province of Camarines sur) SS.

AFFIDAVIT OF LOSS
I, Felomina C. Vergara, of legal age and residing/with address at Zone 5, Talojongon, Tigaon,
Camarines Sur under oath, state:

1. THAT sometime on October 2022 at Naga City while Transacting Business at GSIS Naga
City I accidentally lost my UMID GSIS Card.

2. THAT I exerted diligent efforts to locate it or but to no avail and I therefore considered the
same as lost and can no longer be found;

3. THAT I am executing this Affidavit to attest to the truth of the foregoing facts and to use the
same for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I hereunto affix my signature this 5th of January 2023 at Talojongon, Tigaon
Camarines sur.

FELOMINA C. VERGARA
Affiant

SUBSCRIBED AND SWORN to before me this exhibiting his/her validly issued government ID as
indicated below.

Government Issued ID: ________________

License No: __________________
Issued On: ______________

Person Administering Oath