Republic of the Philippines} Province of Cebu } } x- - - - - - - - - - - - - - - - - - - -x

AFFIDAVIT OF LOSS
I,____________________ Filipino, of legal age and _____________________________City, under oath hereby declare: a resident of

That I am a permanent employee of the Local Government Unit of Cebu City stationed at the City City Office;

That I am a bona fide member of the Government Service Insurance System (GSIS) duly issued a Certificate of Membership effective October 4, 2013;

Sometime in ________2013 however, the said document got lost inadvertently from my possession attributable to the fact that we transferred from cebu City;

Despite diligent efforts to locate the same, it could not anymore be retrieved nor found. All I have in my possession is a photocopy of the first page of the same document now annexed to this affidavit and made an integral part hereof; and,

I am executing this affidavit to attest to the truth of all the foregoing and in support to my claim for benefit with the GSIS.

IN WITNESS WHEREOF I have hereunto affixed my signature this ___ day of December, 2013 at Cebu City

__________________ Affiant

SUBSCRIBED AND me his Community Tax Certificate No. ______________________, 20__ at Cebu City.

________________, ___________________,

SWORN issued on

to

affiant

before

me

exhibiting

this ___

to

NOTARY PUBLIC