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SSSForm Affidavit Death Claim Benefits
SSSForm Affidavit Death Claim Benefits
3 A
City / Municipality of ___________ ) S.S.
_______________________________ )
Province of ____________________)
LEGITIMATE/ LEGITIMATED/ DATE/ PLACE OF BIRTH (if minor, give name, address and
LEGALLY ADOPTED CHILDREN
relationship of guardian)
ADDRESS
MOTHER/FATHER (if dead, give date and place of death instead)
LEGALLY MARRIED?
YES NO
Th at a f f i a n t f u r t h e r c e r t i f y t h at t h e d o c u m e n t s e s t abl i s h i n g t h e fa c t / s o f
__________________ such as the ______________________ could not be submitted for the
following reasons: __________________________________________________________________
FURTHER, AFFIANT SAYETH NAUGHT.
AFFIANT
NOTARY PUBLIC
Until_______________________
DOC NO.: ______________________