Republic of the Philippines)

City of Makati                       ) S.S.

x---------------------------x

AFFIDAVIT OF LOSS

I, MARIA C. DELA CRUZ, of legal age, married, Filipino citizen, and a resident of
3333 Hormiga Street, Valenzuela, Makati City, after being duly sworn to in accordance with law,
depose and state that:

(1) I am a government employee and a member of the Government Service Insurance

System (GSIS);

(2) Being a member of the GSIS, I was issued a GSIS Policy Contract under CM-473173;

(3) I used to keep the said Policy Contract in our home;

(4) Recently, I search for the said Policy Contract because my policy already matured but
I could no longer find the same;

(5) Said document must have been lost when I transferred residence from Paco, Manila to
Poblacion, Makati City;

(6) Despite diligent search and effort to locate the said Policy Contract, the same could
not be found such that I now consider it lost beyond recovery;

(7) As such, I am executing this Affidavit of Loss to attest to the foregoing and for any
legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 8th day of June 2018 in
Makati City.

MARIA C. DELA CRUZ

Affiant

SUBSCRIBED AND SWORN to before me this 8th day of June 2018 in the City of
Makati, Philippines, affiant exhibited to me her Unified Multi-Purpose ID CRN-111-222-3333-1
as valid proof of identity.

Doc. No. _____

Page No. _____
Book No. _____
Series of 2018.