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Affidavit of Surviving Spouse

This document is an affidavit of surviving spouse submitted to the Government Service Insurance System (GSIS) of the Philippines. [1] The affiant declares that they are the widow/widower of a deceased GSIS member/retiree and have not remarried or entered a common-law relationship since the death of their spouse. [2] The affiant acknowledges that their survivorship benefits from GSIS will terminate if they remarry or enter a relationship, and they agree to reimburse any unduly received benefits after termination. [3] The affiant authorizes GSIS to verify their civil status with relevant government agencies and executes the affidavit to attest to the truth of their statements in support of their survivorship

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78 views2 pages

Affidavit of Surviving Spouse

This document is an affidavit of surviving spouse submitted to the Government Service Insurance System (GSIS) of the Philippines. [1] The affiant declares that they are the widow/widower of a deceased GSIS member/retiree and have not remarried or entered a common-law relationship since the death of their spouse. [2] The affiant acknowledges that their survivorship benefits from GSIS will terminate if they remarry or enter a relationship, and they agree to reimburse any unduly received benefits after termination. [3] The affiant authorizes GSIS to verify their civil status with relevant government agencies and executes the affidavit to attest to the truth of their statements in support of their survivorship

Uploaded by

attyjohngarcia
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Republic of the Philippines )

_____________________ ) SS.

x- - - - - - - - - - - - - - - - - - - - - x

AFFIDAVIT OF SURVIVING SPOUSE

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.

___________________________________

Affiant

SUBSCRIBED AND SWORN TO before me this _____ day of _________ at


________________ affiant exhibited to his/her competent evidence of identity by
way of _________________ issued on __________________ in _______________,
Philippines.

Notary Public

Doc. No. ______;

Page No. ______;

Book No. ______;

Series of ______;

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