GSIS LOAN BORROWER’S

DECLARATIONS / MANIFESTATIONS

I solemnly declare / manifest:

That I, ________________________________, ___________________ of

(Name of Employee) (Position)
___________________________, this Division.
( Name of School)

Has no pending administrative charges / cases in the DepEd and in any

administrative tribunals;

Has no pending criminal charges / cases in any criminal courts within the
outside the Philippines.

That I am liable for deception, dishonesty and misrepresent in the event that
the above information is not rue and correct.

That the DepEd’s Authorized Indorsing Official for my loans with the
Government Service Insurance System (GSIS) is free from any liability/ies arising
from the aforesaid transaction with falsified information/s.

This Declaration / Manifestation is made to support the certificate signed by

the DepEd’s authorized indorsing official in the GSIS loan application forms that I
have no pending administrative and / or criminal charge/s.

Done this ______________ day of _____________ General Santos City,

Philippines.

___________________
Teacher-Borrower
(Printed Name over Signature)
CP no: _________________

SIGNED IN THE PRESENCE OF:

_________________________ _________________________
School Head/Principal Teacher
(Printed Name Over Signature) (Printed Name Over Signature)