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CITY/MUN. OF _____________ ) S.S.



WE, ________________________, ______________________,

____________________, and ____________________, all of legal age, Filipinos and
residents of ________________________________, after being duly sworn to in accordance
with law, depose and state THAT:

1. We are the surviving children of _____________________ who who died on

_______________ in ________________ and his deceased spouse __________________;

2. That our parents were survived by the following children/heirs:

Full Names of Children/Heirs Dates of Birth

1. ______________________ ___________________
2. ______________________ ___________________
3. ______________________ ___________________
4. ______________________ ___________________

3. As evidence of our legal relation to the deceased, photocopies of our birth certificates are
herein attached; and

4. We are executing this affidavit in good faith to attest to truth that there is no other heir or
heirs except for the above-named heirs of the said deceased spouses and for whatever legal
purpose it may serve.

IN WITNESS WHEREOF, we have hereunto set our hands

this ___________________ in Makati City, Metro Manila, Philippines.

____________________ ____________________
Affiant Affiant
SSS ID No. _____________
SSS ID No. _____________

____________________ Affiant
Affiant SSS ID No. _____________
SSS ID No. _____________

SUBCRIBED AND SWORN TO before me this ___________________ in

_________________, Philippines, affiants exhibiting to me their SSS Identification Cards as
Competent Evidence of Identity (CEI).

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2013.