Republic of the Philippines)

City of Sorsogon ) S.c.

AFFIDAVIT

I_________________, 14 years of age, Filipino, single and with postal

address at _________________ Sorsogon after being sworn in accordance
with law, do hereby depose and state:

1. That I am one of the surviving heir of ________________ who died

intestate at _________________, Hospital on April 27, 2015;

2. That my mother was bonafide member/borrower of

______________ Incorporated whereby she secured an insurance in
connection with her loan during her lifetime and is entitled to all
the claims and benefits arising from her insurance;

3. That I am currently processing for the death claim/ insurance

benefits of my mother before the ______________ Incorporated;

4. That I hereby attest that I am the named beneficiary of

__________________ in the said insurance;

5. That I am executing this affidavit to attest to the foregoing facts.

In witness whereof, we have hereunto affixed our signature this

___th day of ________________2015 at Sorsogon City, Philippines.

______________________

SUBSCRIBED AND SWORN TO before me this ___th day of

_______________2015 at Sorsogon City, affiants having exhibited to me
her Olongapo National High School ID.