REPUBLIC OF THE PHILIPPINES

(PLACE)

AFFIDAVIT

I, , of legal age, Filipino and residing at

after having been duly sworn in accordance with law, do hereby depose and state:

1. That I am a Plan Holder for ST. PETER LIFE PLAN under LPA No. 448744. Plan Type
St. Christopher, Total Amount Payable PhP 50,000.00
2. That I am executing this affidavit to prove my willingness to transfer the plan to the
deceased, J , and for whatever legal purpose it may serve.

Affidavit further sayeth none.

(NAME)
Affidavit
ID No. ___________
Issued on _ _ __

Conforme:

ST. PETER LIFE PLAN

Represented by:

_____________________________
Valid ID ___________
Issued on ___________
Valid Until ___________

SUBSCRIBED AND SWORN to before me this __________________________ at

_____________________________.