REPUBLIC OF THE PHILIPPINES ) ____________________________ ) SS.

AFFIDAVIT OF LOSS I, ESTER A. BALCITA, of legal age, Filipino, married, and resident of Santa Cruz, Laguna, after being duly sworn according to law, hereby depose and state that: 1. I am a holder of a GSIS Policy Contract with Numbers 51102402093 which was issued in 2005 by the Government Service Insurance System; 2. I could not remember where I placed the said Policy; 3. Despite diligent efforts exerted, I could no longer locate, find or recover the same, and to the best of my knowledge, the same is truly lost; 4. I have no reason to believe or suspect the said POLICY is in possession or control of any other person; 5. I am executing this Affidavit to attest to the truth of the foregoing statements. AFFIANT FURTHER SAYETH NAUGHT. IN WITNESS WHEREOF, I have hereunto ___________________ at _________________________. set my hand this

ESTER A. BALCITA Affiant

SUBSCRIBED AND SWORN to before me this ____________________, affiant exhibited to me his/her Competent Evidence of Identity by way of _________________.

Notary Public

Doc. No. _____. Page No. _____. Book No. _____. Series ________.