REPUBLIC OF THE PHILIPPINES) _____________________________) SS.
AFFIDAVIT OF LOSS I, JON SNOW, Filipino, of legal age, and a resident of Planet of the Apes, 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.
ROWENA P. VINEGAS 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.
Doc. No. . ; Page No. . ; Book No. . ; Series of 2011.
