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Republika ng Pilipinas

KAGAWARAN NG EDUKASYON
Rehiyon XII
SANGAY NG MGA PAARALANG LUNGSOD
Lungsod ng Heneral Santos

GSIS LOAN BORROWERS


DECLARATION / MANIFESTATION
I solemnly declare / manifest:
That I, _________________________________________, _______________of
(Name of Employee)
(Position Title)
___________________________________________________________, this division
(Name of School)
has no pending administrative criminal charges / cases in any criminal courts
within and outside the Philippines;
has no pending criminal charges / cases in any criminal courts within and outside
the Philippines;
That I am liable for deception, dishonesty and misrepresentation in the event that
the above information is not true and correct;
That the DepEds Authorized Indorsing Official for my loans with the Government
Service Insurance System (GSIS) is free from any liability/ies arising from aforesaid
transaction with falsified information/s.
This Declaration / Manifestation is made to support the certification signed by the
DepEds Authorized Indorsing Official in the GSIS loan application forms that I have no
pending administrative and / or criminal charge/s.
Done this _______________ day of ________________, 2011, General Santos
City, Philippines.

______________________________
Teacher Borrower
(PRINTED NAME OVER SIGNATURE)

SIGNED IN THE PRESENCE OF:

________________________________
School Head / Principal
(PRINTED NAME OVER SIGNATURE)
Witness

______________________________
Teacher
(PRINTED NAME OVER SIGNATURE)
Witness

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