REPUBLIC OF THE PHILIPPINES)

_____________________________) SS.

AFFIDAVIT OF LOSS

I, _____________, Filipino, of legal age, and a resident of ________________, after

having been duly sworn in accordance with law, hereby depose and say:

1. That I am a holder of a temporary Unified Multi-Purpose Identification Card

issued by the Government Service Insurance System or GSIS;

2. That I used to put said temporary UMID Card in my pouch;

3. That sometime on August 21, 2016, when I arrived home from work, I
discovered that my temporary UMID card was no longer in my pouch where I
used to place it;

4. Despite diligent search and efforts to locate said document, I could not
find it.

5. That said temporary UMID Card was not confiscated by the authorities of
company by reason of any violation of company rules and regulations;

6. I am executing this affidavit to comply with the requirements of the GSIS

for the reconstitution of said document.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____day

of ____________ 20___ at ____________, Philippines.

______________________

SUBSCRIBED AND SWORN TO before me, a notary public in and for

_____________________ this ____ day of ____________ 20___. The affiant, whom I
identified through the following competent evidence of identity:
_____________, valid from______ to______ issued by_______________, personally
signed the foregoing instrument before me and avowed under penalty of law
to the whole truth of the contents of said instrument.

Notary Public
Doc. No. ........;
Page No. .......;
Book No. .......;
Series of 2011.