{on Non-Marriage / Non-Cohabitation) Form No, 01222018-S0S$-REVO Fy ‘SELF-DECLARATION OF SURVIVING SPOUSE GSIS I, (name of widow/widower), of legal age, Filipino, and a resident of , hereby state as follows: | have not remarried, cohabitated with another person, or otherwise engaged in a common-law relationship since the death of my spouse, (name of spouse). | acknowledge that, if granted, my entitlement to survivorship benefit from the GSIS will be automatically and permanently terminated the moment | re-marry, co-habit with any person, or engage in a common-law relationship. | undertake to reimburse/return to the GSIS, without need of demand or judicial action, all survivorship benefits that | may unduly receive after my entitlement thereto is terminated as stated above. | 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 Date