OMNIBUS SWORN STATEMENT

REPUBLIC OF THE PHILIPPINES)

CITY OF LEGAZPI )S.S

AFFIDAVIT
I, ________________________of legal age, Filipino citizen and a
resident of_____________________________,(_______________________)
Position Title
at __________________________________________, Albay, after having
(Name of School/Office)
sworn in accordance with law, do hereby depose and state that:

1. I am applying for GSIS Loan/s

2. I am with PERMANENT status: ( ) Elementary ( ) Junior High

School ( ) Senior High School;

3. I have NO Pending: ( ) Administrative ( ) Civil ( ) Criminal

charge filed against me in any forms as of this writing;

4. In case of separation from the service (Retirement, Resignation,

Transfer to another Agency/Division or other causes of
separation) I will inform the Agency of my obligation accruing to
GSIS and settle the same accordingly.

5. I am executing this Omnibus Sworn Statement to attest to the

truth of the forgoing facts and to enable the Agency to process
my GSIS Loan application under pain of administrative, civil
and/or criminal liability sanctioned under existing laws.

IN WITNESS WHEREOF, I have hereunto set my hand

this____day of _______________________, Albay, Philippines.

_________________________
(GSIS Member-Loan Applicant)

SUBSCRIBED AND SWORN to before me this____day

of_______________,20__ at__________________, Albay. affiant exhibiting
to me his/her____________issued
on_________________at_________________.
(Person Administering Oath)