REPUBLIC OF THE PHILIPPINES)

PROVINCE OF LA UNION )
MUNICIPALITY OF ARINGAY )

AFFIDAVIT OF FUNERAL EXPENSES

I, , of legal age,
resident of , Filipino citizen, after being
sworn in accordance with law depose and say:

1. That on my
died and a wake was
held in his honor starting .
2. That by the reason of the wake and burial of my
we incurred some expenses broken down as follows:
a. Funeral Service Package (Casket, Embalming, etc.) in the
amount of .
b. Construction of Tomb in the amount of

c. Church services in the amount of P

d. Food in the amount of P

Total:

3. That I am executing this affidavit to attest to the truth of the

foregoing and in support of securing burial/funeral benefits of
our deceased .

In witness whereof, I have hereunto set my hand this

day of at Aringay, La Union.

___________________________________
CTC No.___________________________
On:_______________________________
At: Aringay, La Union

Subscribed and sworn to before me t his at

Aringay, La Union.