Republic of the Philippines )

Roxas City ) S.S

AFFIDAVIT OF SUPPORT

I, AA, of legal age, Filipino, single, and a resident of __________________________, after

having sworn to in accordance with law do hereby depose and state that:

1. That I am presently employed as ___________________________

2. That due to Cardiopulmonary Arrest, my father _________________ died last

September at the age of 85;

3. That being of old age and having no means of income, my father was dependent on me
for support and sustenance during his lifetime;

4. That I am executing this affidavit to attest to the veracity of the foregoing facts and in
order to avail the assistance to its members;

IN TRUTH WHEREOF, I have hereunto set my hand and affix my signature this 23 rd day of
October 2018 at Roxas City, Capiz.

A
Affiant

ID Number:
Issued at:

SIGNED IN THE PRESENCE OF:

SUBSCRIBED AND SWORN TO before me this day of ______ at_______________,