REPUBLIC OF THE PHILIPPINES )

City of Iloilo ) s.s.

x-----------------------x

AFFIDAVIT OF LOSS

I, JOSE A. DELA CRUZ, Filipino, of legal age, married, and with

residence at Landheights 3, Phase 2, Buntatala, Jaro, Iloilo City, Philippines
after being duly sworn to in accordance with law, hereby depose and
state:

That I was issued a UMID by GSIS Iloilo;

That the said GSIS UMID, which has always been in my possession,
was lost
and its whereabouts cannot be ascertained despite due and
diligent search
made and undertaken such that I now believe that the same is lost
beyond
recovery;

Therefore, I am executing this Affidavit of Loss to attest to the truth

of the foregoing and to support my application for the issuance of a
new identification card, in lieu of the one that was lost.

IN WITNESS WHEREOF, I have hereunto set my hand this July 28, 2017
at Iloilo City, Philippines.

JOSE A. DELA CRUZ

Affiant
Employment ID No. 2004-02-DCD01
Issued by: Iloilo Provincial Capitol

SUBSCRIBED AND SWORN before me this 28th day of at Iloilo City,

Philippines. Affiant exhibited to me his Identification Card identified by me
through competent proof of identity as defined by the 2004 Rules on
Notarial Practice pursuant to EN BANC A.M. No. 02-8-13 SC Resolution.

Doc. No.530 ;
Page No. 109 ;
Book No. 01;
Series of 2017.