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Republic of the Philippines)

CITY OF ZAMBOANGA. . . . . ) S.S.


x- - - - - - - - - - - - - x
AFFIDAVIT OF LOSS
I, _____________, of legal age, married, and residing
at _______________, Zamboanga City, after having been sworn
in accordance with law, hereby depose and say:
That I am an employee of the _________________ and as
such, I am a member of the Government Service Insurance
system;
That I have been issued a GSIS e-Card by the GSIS
Branch in Zamboanga City, Philippines, thru the Union Bank
Zamboanga Branch;
That the said e-Card was lost or discovered from my
possession;
That I have exerted diligent efforts in the search for
the said e-Card but all proved futile and that the same is
now beyond recovery;
That I am executing this affidavit in order to
establish the loss of the said e-Card as a fact for all the
purposes that this may serve under the law;
IN WITNESS WHEREOF, I have hereunto set my hand on this
___ day of _______ in the City of Zamboanga, Philippines.
_________________
Affiant
SUBSCRIBED AND SWORN to before me on this ___ day of
__________ in the City of Zamboanga Philippines.
Doc. No.___
Page No.___
Book No.___
Series of 2013