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 set my hand this ___________________ at _________________________.

ESTER A. BALCITAAffiant

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 ________.