RET ~ 01224 (12.2015) REPUBLIC OF THE PHILIPPINES —_) SS. CITY/PROVINCE OF. AFFIDAVIT (Funeral Expenses) fo, egal age, single/married, Filipino and presently residing at after having been duly sworn in accordance with law hereby depose and say 1. That 1 personally know the fact of death of the deceased, who died at on because he/she was my 2. That the deceased was a member of the Social Security System with SS Number and covered under his/her last employer with business address at 3. That as , | actually paid his/her funeral expenses in the amount of F. Token down as follows: materials for coffin/cremation Para intermentitransportation services food & other miscellaneous expenses during the wake others (specify) aocm R 4. That | am executing this affidavit to attest to the truth of the foregoing statements and to support my claim for SSS benefit, in the absence/unavailability of the Official Receipts for funeral expenses. FURTHER, affiant sayeth none. Signature Over Printed Name of Affiant SUBSCRIBED AND SWORN TO before me this day 20__ at , Philippines, affiant having exhibited to me his/her two (2) valid identification cards_ bearing his/her picture and signature as competent evidence of identity NOTARY PUBLIC/ ADMINISTERING OFFICER Doc. No. Page No Book No. Series of 20.