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Annex A - 3

GSIS Form No. SURV-2011-02-004


Date Revised: 2010-03-16

REPUBLIC OF THE PHILIPPINES)


PASAY CITY
)S.S.

AFFIDAVIT OF LEGAL/CERTIFIED GUARDIAN


OF MINOR DEPENDENT CHILD
I, __________________________________________________________________, of
legal age, Filipino, with address at ___________________________________________ and the
following contact number _______________________, after having sworn in accordance with law,
hereby depose and state:
I am the __________________ (state relationship with the child, i.e. father/mother, etc.)
and legal guardian of _____________ (name of child), a child of the late
___________________________________, who was a GSIS member / retiree, who died on
___________________ at _________________________________;
I hereby declare that the above-named child is the youngest (or, second youngest/third
youngest, etc.) of the deceased; that he/she is not more than 18 years of age.
I am fully aware that if the said child is granted survivorship benefit by the GSIS, his/her
entitlement thereto will automatically and permanently terminate the moment he/she is over
eighteen. Consequently, I hereby unconditionally make myself personally and solidarily liable with
the child for whatever survivorship benefit the latter may still unduly receive from the GSIS after
his/her entitlement thereto is terminated as stated above.
I am executing this affidavit to attest to the truth of the foregoing statements in support of
the application for survivorship benefit of ___________ (name of child) under Republic Act No.
8291 and for what other legal purposes it may serve. I fully understand that any inaccurate and
untruthful statement in this affidavit shall render me criminally and civilly liable.
______________________
Affiant
SUBSCRIBED AND SWORN to before me this ______ day of _________________20__, in
the City of Pasay, Philippines, affiant exhibiting to me his/her ______________________as
Competent Evidence of Identity (CEI):
NOTARY PUBLIC
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Until Dec. 31, 20___


PTR No. : _________________
IBP No. : _________________
Roll No. : _________________