REPUBLIC OF THE PHILIPPINES)

PROVINCE OF ___________________ )S.S

MUNICIPALITY OF ___________________ )
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AFFIDAVIT OF TWO DISINTERESTED PERSONS

We, ___________________ and ___________________, both of legal age,

Filipino citizens, and residents of Brgy. ___________________ and
___________________, respectively, after having been duly sworn to in accordance with
law, hereby depose and state:

1. That we know personally the late ___________________, born to the late

___________________ and ___________________, of Brgy.
___________________. We have known ___________________ for a long time
since we are close family friends;

2. That we know for a fact that the true and correct name of his mother is
___________________;

3. That, however, upon his death and when her relatives were about to process her
benefits with the SSS, one of the requirements is the Certificate of Death of
___________________;

4. In the said Certificate of Death of ___________________, the name of his mother

appearing therein is ___________________, instead of ___________________,
the latter being the true and correct name of the mother of ___________________.
As proof thereof, attached is a copy of the Certificate of Birth of
___________________;
5. That ___________________ and ___________________ refer to one person;
6. That we are not related by consanguinity or affinity to ___________________;

7. That we are executing this Affidavit to establish the truth of the foregoing facts
and to attest to the truth of the foregoing statements for all legal intents and
purposes it may serve.

IN WITNESS WHEREOF, we have hereunto set our hands this __th day of
June 2021, in the ________________________, Philippines.

___________________ ___________________
Affiant Affiant
ID. NO. ___________________ ID NO. ___________________

SUBSCRIBED AND SWORN to before me this this __th day of June 2021, in the
________________________, Philippines.