Republic of the Philippines )

Province of Davao del Norte )s.s.

City of Tagum )

AFFIDAVIT OF LOSS

I, MARIA ELENA FERIDO Y CAVAN, of legal age, married, Filipino, and a

resident of Purok 3, Caranza St., Brgy. La Filipina, Tagum City, Davao del Norte,
Philippines, after having been duly sworn to an oath in accordance with law hereby
depose and say:

1 That I am a duly registered member of the Government Service Insurance

System (GSIS);
2 That I was issued a Unified Multi-Purpose Identification Card (UMID) by the
GSIS with number CRN-006-0027-8888-7;
3 That I placed the aforesaid card in my wallet;
4 That sometime on June 1, 2015 while at my place of work at Apokon
Elementary School of the Department of Education (DepEd) at Apokon,
National Highway, Tagum City, Davao del Norte, I lost the said wallet together
with all the contents therein;
5 That after diligent search and inquiry, same could not be found and I now
presume the wallet and all the contents thereof, including the aforesaid GSIS
UMID Card, as lost for all intents and purposes;
6 That I execute this affidavit to prove the truth of the foregoing.

IN WITNESS WHEREOF, I set forth my signature this 13 th day of August, 2015 at

Tagum City, Davao del Norte.

MARIA ELENA C. FERIDO

AFFIANT
PRC ID# 0273876
Issued on 1/3/14
Issued at Davao City

SUBSCRIBED AND SWORN TO BEFORE ME this 13th day of August, 2015 at

Tagum City, Davao del Norte, with affiant exhibiting her above indicated PRC ID.

Doc. No.: ___;

Page No.: ___;
Book No.: ___;
Series of 2015