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REPUBLIC OF THE PHILIPPINES…..) SSS FORM CLD-1.

3A
City of Cebu……………………………….) S.S.
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AFFIDAVIT OF DEATH BENEFIT CLAIM

I, JOSEFINA C. TAMAYO, of legal age, widow, and presently residing at Ybanez


Compound., C. Padilla St., Mambaling, Cebu City, having been sworn according to law, depose
and say:

That I am the widow of the late CARMELO S. TAMAYO, who died at Adventist Hospital
Cebu, 400 Tres De Abril St., Cebu City on August 29, 2016.

That the names and pertinent data of the aforementioned deceased member’s
immediate relatives and next to kin are as follows:

LEGITIMATE HUSBAND/WIFE DATE & PLACE OF MARRIAGE ADDRESS


Municipal Trial Court, Ybanez Compound, C. Padilla
Josefina C. Tamayo
Minglanilla, Cebu St., Mambaling, Cebu City

COMMON-LAW
DATE OF UNION ADDRESS
HUSBAND/WIFE
none n/a n/a

LEGITIMATE/LEGITIMATED/ (If minor, give name, address


DATE/PLACE OF BIRTH
LEGALLY ADOPTED CHILDREN and relationship of guardian)
none n/a n/a

ILLEGITIMATE CHILDREN DATE/PLACE OF BIRTH ADDRESS


None n/a n/a

MOTHER/FATHER ADDRESS STATUS


Ramon Tamayo (deceased)
LEGALLY MARRIED
Juanaria Sison (deceased)

AFFIANT FURTHER SAYETH NAUGHT.


____________________
Affiant

SUBSCRIBED AND SWORN to before me this 23rd day of September 2016 at Cebu City,
Philippines, affiant who is personally known to me and exhibiting to me the following:
Competent Evidence of Identity
Affiant
Type of ID ID Number and Expiry Date (if applicable)
JOSEFINA C. TAMAYO 1 SSS 06-0289149-7

MURLI MANOHAR DAS E. BRISTOL


Notary Public
Doc. No. 3 Until December 31, 2017
Page No. 1 Roll of Attorneys No. 65081
Book No. 1 IBP Lifetime No. 015129
Series of 2016 PTR No. CEB1042034 (07.22.16)