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REPUBLIC OF THE PHILIPPINES )

CATBALOGAN CITY, SAMAR )S.S

AFFIDAVIT OF SURVIVING SPOUSE


I, MA. TERESA BALANI VDA DE ECLIPSE, Filipino, of legal
age, widow with address at Purok 4, Brgy. Mercedes,
Catbalogan City, Samar, having been sworn to in accordance
with law, hereby depose and state that:

1. I am the widow (surviving spouse) of the late Cesar


A. Eclipse, a GSIS member, who died on October 23,
1988, while at his post in Brgy. Lagundi, Catbalogan
City;

2. Since the demise of my afore-named husband, I


have not remarried;

3. I hereby agree to allow the GSIS to stop paying the


survivorship benefits due me, if and when I do
remarry or contract a second marriage;

4. In this regard, I hereby authorize the GSIS to secure


from the Philippine Statistics Authority or any other
agency any information concerning my CIVIL
STATUS;

5. I am executing this affidavit to attest to the truth of


my foregoing statements and in support of my claim
for the confirmation of my survivorship benefits under
Republic Act 8291.

MA. TERESA BALANI VDA DE ECLIPSE


Affiant

SUBSCRIBED AND SWORN to before me in Catbalogan


City this 14th August, 2018 by MA. TERESA BALANI VDA DE
ECLIPSE, who has satisfactorily proven to me her identity
through City Health Office ID Number 227 issued at Catbalogan
City, Samar valid until _________.

Doc. No. _____;


Page No. _____;
Book No. _____;
Series of 2018.