I, _______________________________, Filipino, of legal age, widow/widower, with address at ____________________ and the following contact number ____________________, after having sworn in accordance with law, hereby depose and state:
I am a widow/widower of ____________________ who was a GSIS member/retiree who died on ____________________ at ____________________;
I hereby declare that, since the death of my spouse, I have not remarried, cohabited with another person, or otherwise engaged in a common-law relationship. I acknowledge that, if granted, my entitlement to survivorship benefit from the GSIS will automatically and permanently terminate the moment that I re-marry, co-habit with any person/engage in a common-law relationship, whether of the same or opposite sex, or, whether or not such a relationship is still subsisting. I hereby agree unconditionally to reimburse/return to the GSIS, without need of demand or judicial action, all survivorship benefits I may still unduly receive after my entitlement thereto is terminated as stated above.
Pursuant to and consistent with the declaration I made above, I hereby authorize the GSIS to secure information regarding my civil status from the National Statistics Office (NSO) or other relevant government offices or even private entities.
I am executing this affidavit to attest to the truth of the foregoing statements in support of my application for survivorship benefit with the GSIS under Republic Act No. 8291 and for 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.
IN WITNESS WHEREOF, I have hereunto set my hand this ____ day of ___________ 20____ in ____________, _____________, Philippines.