Republic of the Philippines )

Province of Tarlac
) S. S.
Municipality of Capas
)

AFFIDAVIT OF ADDITIONAL
FUNERAL EXPENSES
I, _____________________________________________, of legal age, Filipino and a
resident of ____________________________________________________________________,
after being duly sworn in accordance with the law, herby deposed and say:
1. That ___________________________ died on _________________________________,
in __________________________, who in his/her lifetime, was a member of Social
Security System (SSS) under SSS No. ________________________________________;
2. That being his/her _______________________, I personally attended to the wake, burial
and interment of the said deceased, where I spend the amount of
_______________________________________________
(P______________________) representing the funeral services rendered for his/her wake
and
burial,
a
copy
of
receipt
issued
by
the
_____________________________________________________________
which
rendered the said services is hereto attached and marked as Annex A, the same to be
made an integral part hereof;
3. That aside from the foregoing expenses, I incurred additional expenses in connection
with the wake and burial of the said deceased broken down as follows:
_____________________________
_____________________________
_____________________________
_____________________________

_ _ _ _ _ _ _ _ _ _ _ _ P _____________
_ _ _ _ _ _ _ _ _ _ _ _ P _____________
_ _ _ _ _ _ _ _ _ _ _ _ P _____________
_ _ _ _ _ _ _ _ _ _ _ _ P ______________
__________________
Total Expenses
P_______________
4. That the foregoing expenses was actually, directly and exclusively spend for the burial of
the said deceased;
5. That I have executed this affidavit for the purpose of filing a claim for funeral/death
benefit with the Social Security System;
6. That I attest to the truthfulness of the foregoing statements being of my own personal
knowledge, belief and information.
IN WITNESS WHEREOF, I have hereunto set my hand this _______________________
at the Municipality of Capas, Province of Tarlac, Philippines.
____________________________
Affiant
SUBSCRIBED
AND
SWORN
TO
before
me
this
________________________________ at the Municipality of Capas, Province of Tarlac,
Philippines.
Doc No. _______;
Page No._______;
Book No. ______ ;
Series of ______.