Republic of the Philippines)

City of Kabankalan ) S.S

X------------------------------X

I, ALLAN PINEDA, of legal age, filipino, widow, and a resident of

Kabankalan City, Philippines after having duly sworn to in accordance
with law hereby depose and state that;

1. I am the husband of JENNY PENIDA who died on September 24,

2018 at CLMMR HOSPITAL, Bacolod City due to Malignant Cancer;

2. I am attesting that my wife died on the said date;

3. That I execute this affidavit to attest to the truthfulness of the

forgoing declarations and for the purpose of asking for burial assistance
from the Office of the City Mayor, Kabankalan City, Philippines.

IN WITNESS WHEREOF, I hereunto affix my signature this 26 th day

of September 2018 at Kabankallan City, Philippines.

ALLAN PINEDA
Affiant
Community Tax Certificate No. 19965623

SUBSCRIBE AND SWORN to before me this 26th day of September

2018 at kabankalan City, Philippines.