rene GUARDIAN OF MINOR OR DEPENDENT CHILDREN Fonm No. 08242017-A8LH re AFFIDAVIT OF SURVIVING HEIRS/SURVIVING SPOUSE/ sis Note: Fil in ail the blanks completely and correctly. Write NONE or NOT APFLIZABLE, If Is such. Incorrect or incomplete information may cause delay, REPUBLIC OF THE PHILIPPINES ) CITYIMUNICIPALITY OF. ss AFFIDAVIT OF SURVIVING HEIRS/SURVIVING SPOUSET GUARDIAN OF MINOR OR DEPENDENT CHILDIREN ‘After having been duly sworn to In accordance with lav, Uwe hereby deposa-end state as follows: 4, Name in ful of deceased member/pensionerretirea, 2. Residence of deceased at the time of dont 3, Name of office/position af the decensed 4, Date end place of bith of the deceased Sale and place ef dai of ne deceased a se ilsaon eo, alaah a carted Wie Gav a ant of Frdherealgt atthe deceased under adminisirailon? 1 attach @ ceriified tii Gary of appointment of |. Dovlaration of Surviving Hels ‘The deceased Is survived by the following halts: . a) Widow or widower _ 5) Chiidren (Include aif children whether leglimete, loylimated, lagally adopted, er Waqiimmate, Attach thelr bith cettticates andior adoption papers. in the absence of any chidran In any of the categories, the word NONE Instead of the words NOT APPLICABLE should 20 clearly Indicated Lunider such categoryiles Legitimatedegilimated’ _Logally Adoptedititeyitimate Warne Bate of Birth ©) “Father and mother of the degbased In. the absence of . legtimate/d children: 4) Paternal and’matemal grandparonte lithe absence of parsons under lima (0) & (ejabove ©) Brothers and sisters in the absence af persons under Ita 6) & (above Name | Date of Birth [Order of ‘Relationship (e.g. full above:ooe of aration of Suviving Spo I, eae OF WidOWHidOWEN), have fot romartied, Sohabited wilh anther Person, or olhoriise engaged i a common-law relationship slnce the daalh of my, Spouse. | acknowledge that, If granted, my entilement to survivorsilp benefit from the GSIs, wit Putomaticaly and permanant terminate the moment that | re-marry, co-habl wth any person, oF engage cp aeneT-taw relalonship, whothor ofthe same or opposite eex, and whether such a rolalonsisp stl subsisting a1 aby ftatee uncondlionaly to relmburse/retum to thé GBIS, without need of demand or judictal action, Sh Survivorship beneits thet 1 may unduly receive after my enillemort thereto Is lormninetee oe wise above, il. Declaration of Guardian of Minor ead/or Dependent Children, —. ae ____ (name of guardian) am the Blas andthe Tagaigualan ot etait (lationship with the children, e.g, taherinother/atnttcte, ofc.) and the legal guardian of the following minor and/or neapacitated ovlidirge Orban By Ratan ho Ite blow 18 are lt (Flamin or savorshin Dai unor RA P267) Snnarcnt 24 years of age (it claiming for survivorship benef under PD 1946) andlor Inaccottoe children, oyordless of age, shoul be mnctidedin theft - _| ‘Naine of MINOR or Dato of Binh. | Grdar of Birth] — Waite oT Taeapaciiy DEPENDENT children _ _—ifappticabte) "| Informelion ors see ena wih the deviations made above, we hereby authorize the GIS to secure treeacn from the Philippine Staleice Authorly (PSA). oreiher tela goat offices, or private entities to validate or check the fats Mervin daciared, ive fully understand that any inadcuraie and untruthful statement in this aflidavit shall render me/us: criminally end clvily fable. Parent Afiant i ee* Page 3 0f 3 and , both of legal age, a reby confirm the foregoing slatemenis|of the dlaimant/s to be true ai We single/martied, hereby confirm the foregoing statements) of the daimant/s to be true and correct. further state that we have known the deceased for around years and that the deceased was buried at Narie and Signature of Wiinoss Name and Signature of Witness Republic of the Philippines f Municipality/City of 8.8. } BEFORE ME, @ Notary Public for and in this, day of — 20. personally appeared the following: : — Name _ Date of lesue/Expiry Place issued ie acknowledged that the foregoing statements made by them on this document are true and correct to the best of their knowledge and belief, TO THE TRI \UTH OF THE FOREGOING, witness now my hand and seal on the daté and place mentioned above, Dos, No. 1 Notary Public Page No, Book No, Series of