READ ME & DELETE THIS AFTER READING — THIS FORMAT WAS USED TO REINSTATE GSIS

MEMBERSHIP.
AFFIDAVIT OF NEGLIGENCE

REPUBLIC OF THE PHILIPPINES)

CITY/MUNICIPALITY OF XXX ) S.S.
x---------------------------x

I, TYPE NAME HERE IN CAPSLOCK, of legal age, Filipino citizen, and residing at type
address here after being duly sworn in accordance with law, hereby depose and state under oath:

That I am executing this Affidavit voluntarily and without any coercion. That I am aware of the
consequences of making false statements under oath. That I have personal knowledge of the facts
stated herein.

That I, Your Name, a pensioner under the Government Service Insurance System (GSIS), type
the reason you think your pension was discontinued for, declining the continuance of my
survivor (can delete this if not survivor) pension from my late husband, ______ (Can delete this
too if not survivor) resulting in the suspension of my pension.

This negligent act led to the unintended suspension of my GSIS pension. I am executing this
Affidavit to reverse the neglectful act I accidentally committed. I am executing this Affidavit to
reinstate my survivor pension.

I do hereby acknowledge the truthfulness of the above information/details.

YOUR NAME
Affiant

ACKNOWLEDGMENT

REPUBLIC OF THE PHILIPPINES)

CITY/MUNICIPALITY OF XXX) S.S.
x---------------------------x
SUBSCRIBED AND SWORN to before me this 14th day of March 2024, affiant exhibited a
competent proof of their Identity:
Name Proof of Identity

YOUR NAME TYPE ID TYPE &TYPE ID NUMBER IF

APPLICABLE

WITNESS MY HAND and NOTARIAL SEAL, this 14th day of March 2024, at the aforementioned
location.
Doc. No:_______;
Page No:_______;
Book No:_______;
Series of 2024.