Republic of the Philippines )

Province of ________________ )
City of _______________ )
x------------------------------x

AFFIDAVIT

I, _________________________, of legal of age, married, and a resident of

__________________________________, Philippines after having been sworn to in accordance with law,
do hereby depose and state:

1. That I am one and the same person who caused the execution of this instrument;

2. That I am the sister of _________________________ who died on September 10, 2013 in

___________________________, herein attached as ANNEX “A” is a photocopy of his
Certificate of Death;

3. That on April - May 2013, the late _____________________________ had worked on a 20-day
Summer Job at the Office of ______________________ and was assigned at the
____________________________ as ___________________________;

4. That however, in view of his death, he was not able to claim the remaining 40% of his
wage from the said Summer Job;

5. That I am the only surviving relative of ___________________________ and is requesting to

claim the said 40% wage of the latter;

6. That I am executing this affidavit to attest the truth of the foregoing and to apprise the
concerned office regarding such facts and in support on my claim on the 40% wage of
my brother.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of October,
2013 in _____________________________________, Philippines.

_____________________________
Affiant

SUBSCRIBED AND SWORN to before me this ___ day of October 2013, affiant having
exhibited her ID Number __________________ in _______________________________, Philippines.

Doc. No. ________

Page No. ________
Book No. _______
Series of 2013