Republic of the Philippines)

) SAMPLE: MARRIED
)...s.s.

AFFIDAVIT OF CONFIRMATION

I, JUAN CRUZ DELA CRUZ, a Filipino of legal age, a resident of 123 ABCD ST.,
KAMUNING, QUEZON CITY, a bona fide member of the Philippine National Police with the
rank of Police Master Sergeant and presently assigned at DPRM, RMD after having been
duly sworn to in accordance with law, do hereby depose and says that:

1. Pursuant to this affidavit, I am confirming that the following are my legal

beneficiary/ies and/or heir/s, to wit:

NAME RELATIONSHIP BIRTHDATE

JUANA DOE DELA CRUZ WIFE JAN 01, 1985
JOAN DOE DELA CRUZ DAUGHTER FEB 01, 2013
JOHN DOE DELA CRUZ SON MAR 01, 2016

2. My relationship with person/s whose name/s is/are listed above is/are borne out by
the fact that I am the lawful spouse and the father/mother of the afore-mentioned
child/children as evidenced by the attached advisory on marriages, marriage contract
and birth certificate/s;

3. That all the documents I have attached and submitted to support the updating of my
Declared Legal Beneficiary/ies are original copies obtained from Philippine Statistic
Authority (PSA); and

4. I hold myself criminally and administratively liable for perjury and dishonesty should
any statements made herein/documents submitted herewith are inaccurate or later
found to be false and in violation of law.

AFFIANT SAYETH NAUGHT:

Signature PNP Personnel______

Affiant
Contact No. ______________________

SUBSCRIBED AND SWORN to before me this ___________ day of ________________ at

___________________________________, Philippines

Doc. No.
Page No.
Book No.
Series No.
 SAMPLE: SOLO PARENT
Republic of the Philippines)
)
)...s.s.

AFFIDAVIT OF CONFIRMATION

I, JUAN CRUZ DELA CRUZ, a Filipino of legal age, a resident of 123 ABCD ST.,
KAMUNING, QUEZON CITY, a bona fide member of the Philippine National Police with the
rank of Police Master Sergeant and presently assigned at DPRM, RMD after having been
duly sworn to in accordance with law, do hereby depose and says that:

1. Pursuant to this affidavit, I am confirming that the following are my legal

beneficiary/ies and/or heir/s, to wit:

NAME RELATIONSHIP BIRTHDATE

JOAN DOE DELA CRUZ DAUGHTER FEB 01, 2013
JOHN DOE DELA CRUZ SON MAR 01, 2016

2. My relationship with person/s whose name/s is/are listed above is/are borne out by
the fact that I am the lawful father/mother of the afore-mentioned child/children as
evidenced by the attached cenomar and birth certificate/s;

3. That all the documents I have attached and submitted to support the updating of my
Declared Legal Beneficiary/ies are original copies obtained from Philippine Statistic
Authority (PSA); and

4. I hold myself criminally and administratively liable for perjury and dishonesty should
any statements made herein/documents submitted herewith are inaccurate or later
found to be false and in violation of law.

AFFIANT SAYETH NAUGHT:

Signature PNP Personnel______

Affiant
Contact No. ______________________

SUBSCRIBED AND SWORN to before me this ___________ day of ________________ at

___________________________________, Philippines

Doc. No.
Page No.
Book No.
Series No.
 SAMPLE: SINGLE

Republic of the Philippines)

)
)...s.s.

AFFIDAVIT OF CONFIRMATION

I, JUAN CRUZ DELA CRUZ, a Filipino of legal age, a resident of 123 ABCD ST.,
KAMUNING, QUEZON CITY, a bona fide member of the Philippine National Police with the
rank of Police Master Sergeant and presently assigned at DPRM, RMD after having been
duly sworn to in accordance with law, do hereby depose and says that:

1. Pursuant to this affidavit, I am confirming that the following are my legal

beneficiary/ies and/or heir/s, to wit:

NAME RELATIONSHIP BIRTHDATE

JOAN DOE DELA CRUZ MOTHER FEB 01, 1950
JOHN DOE DELA CRUZ FATHER MAR 01, 1952

2. My relationship with person/s whose name/s is/are listed above is/are borne out by
the fact that I am the lawful child of the afore-mentioned parent/s as evidenced by the
attached cenomar and birth certificate/s;

3. That all the documents I have attached and submitted to support the updating of my
Declared Legal Beneficiary/ies are original copies obtained from Philippine Statistic
Authority (PSA); and

4. I hold myself criminally and administratively liable for perjury and dishonesty should
any statements made herein/documents submitted herewith are inaccurate or later
found to be false and in violation of law.

AFFIANT SAYETH NAUGHT:

Signature PNP Personnel______

Affiant
Contact No. ______________________

SUBSCRIBED AND SWORN to before me this ___________ day of ________________ at

___________________________________, Philippines

Doc. No.
Page No.
Book No.
Series No.