Republic of the Philippines…}

Province of Surigao del Sur…}

City of Tandag…} S. S.

AFFIDAVIT OF LOSS

I, JOEL P. MUYCO, Filipino, of legal age and a resident of 005 Navales St.,
Tondo, Bag-ong Lungsod, Tandag City, Surigao del Sur, state under oath, THAT:

1. I am a holder of a Policy Contract with No. CM-5200878 issued by GSIS;

2. I kept said policy in one of my folders which contain also other important
documents;

3. However, the folder which contains my Policy Contract and other important
documents cannot be found in the place where I kept it;

4. I exerted all efforts to locate the same but to no avail;

5. I am executing this Affidavit to attest the truthfulness of the foregoing

statements and for any legal purpose this may serve best.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ day of May
2015, in Tandag City, Surigao del Sur, Philippines.

JOEL P. MUYCO
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, a Notary Public for and in the
Province of Surigao del Sur, this _______ th day of May 2015, in Tandag City, Surigao
del Sur, the affiant personally appeared and affixed his signature and presented his ID
as proof of his identity. .

ANDREI ARREZA ANDRESAN

Notary Public
Until December 31, 2015
Capitol Road, Telaje, Tandag City
8300 Surigao del Sur
IBP No. 811366; Jan. 5, 2015; Surigao del Sur
PTR No. 5427379; Jan. 5, 2015; Surigao del Sur
IBP Roll No. 41883
MCLE Compliance No. IV-00134
SERIAL NO. 05-2014

Doc. No. _______; Page No. _________; Book No. _________; Series of 2015