REPUBLIC OF THE PHILIPPINES )

CITY OF ZAMBOANGA ) SS.

AFFIDAVIT OF LOSS

I, ______________________, Filipino, of legal age, single/married and a resident of

_______________________, Zamboanga City after having been duly sworn in accordance
with law, hereby depose and say:

1. That I am a plan holder of the GSIS, with Policy No. CM 123456789, with
maturity date on _________________;

2. That said Policy was kept together with my other files and documents in our
home;

3. That however, due to inadvertence, said Policy could not be located anymore;

4. That diligent efforts were exerted to locate said Policy but all such endeavors
proved futile and to no avail, hence the same is now considered lost and at a
point beyond recovery;

5. That said policy contract/s had never been encumbered, pledged, mortgaged or
given as a security to any contract with any person or establishment;

6. That I execute this affidavit to attest to the truth of the foregoing facts based
on personal knowledge and for all legal intents and purposes.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

_________________ in the City of Zamboanga, Philippines.

________________________

Affiant
 SUBCRIBED AND SWORN to before this ___________________ in the City of
Zamboanga, Philippines, affiant exhibited his/her _______________ Identification Card
bearing number _________________.

Doc. No. ;
Page No. ;
Book No. ;
Series of 2017.