Republic of the Philippines)

QUEZON CITY, M. M. ) s.s.

x-------------------------------x

AFFIDAVIT

I, __________________, of legal age, married, Filipino and presently

residing at ______________________________, after having been duly sworn
to in accordance with law hereby depose and say:

1. That I am the surviving spouse/claimant of the death benefits from

the Social Security System (SSS) of my late husband
_______________. Attached is the copy of our Marriage Contract
and hereby marked as ANNEX “A”;

2. That my husband, ________________ died on

___________________. Attached is the copy of Certificate of
Death and hereto marked as ANNNEX “B”;

3. That as the spouse of ___________________, I am his legal heir

and the one entitled to claim said benefits from the SSS as
provided for by law;

4. That as a requirement for such claim, I am submitting the list of

the funeral expenses we have incurred, as follows:

a) Coffin – ____________

b) Embalming – ________________

c) Cemetery Lot – ________________

d) Miscellaneous expenses during the wake – _______________

5. That I am executing this Affidavit to attest to the veracity of all the

foregoing facts and for all legal intent and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ______

day of _____________ 2019, in Quezon City, Philippines.

_________________
Affiant

SUBSCRIBED AND SWORN TO before me this _______ day of _________,

in Quezon City, Metro Manila.