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REPUBLIC OF THE PHILIPPINES)

PROVINCE OF SURIGAO DEL SUR)


CITY OF TANDAG) S.S.
X--------------------------------------------------------/

AFFIDAVIT OF FUNERAL EXPENSES

I, GENALYN C. MENDEZ, of legal age married to ERWIN T. MENDEZ and residing at 28 Cabrera St.,
Tandag City, Surigao del Sur, after being duly sworn according to law, depose and say:

1. That I am the Wife of the late Erwin T. Mendez who was insured in the Social Security System and a
member of Pag-IBIG Fund;
2. That Erwin T. Mendez died on September 18, 2014;
3. That I took charge in the interment of the above-mentioned deceased and as such I was answerable for
the burial expenses incidental thereto;
4. That the following burial expenses were incurred in the interment of the deceased;

Funeral Services-----------------------------------P 20,000.00


Cemetery Lot--------------------------------------- 20,000.00
Burial Permit---------------------------------------- 50.00
Coffin------------------------------------------------ 60,000.00
Music------------------------------------------------ _________
Foods, Drinks, Cigarette, etc. served to
The people who come to conclude with the
Bereaved family------------------------------------ 50,000.00
Church Rites---------------------------------------- 500.00
Tomb------------------------------------------------- 20,000.00

Total------------------------------------------------- 170,550.00

GENALYN C. MENDEZ
(Affiant)
CTC no. 03179860
Issued on 1o/08/2014
Issued at Bag-ong Lungsod, Tandag City, Surigao del Sur

CORROBORATION

We, GLORINA F. CABRERA, of legal age, single, Filipino, teacher of Telaje Elementary School,
Tandag City, Surigao del Sur and GRACE C. CURADA, businesswoman from Tandag City, Surigao del Sur, of
legal, widow, Filipino, hereby confirmed the foregoing statements of Genalyn C. Mendez to be true correct:

Signature: ________________________ Signature: ____________________


GLORINA F. CABRERA GRACE C. CURADA
CTC no. 04519612 CTC no. 03179863
Issued on 01/13/2014 Issued on 10/09/2014
Issued at Tandag City, SDS Issued at Tandag City, SDS

SUBSCRIBED AND SWORN TO before me this 10th day of October 2014 in the City of Tandag,
province of Surigao del Sur, Philippines, affiant exhibiting to me, respectively their residence certificate as shown
below their names.