Republic of the Philippines )

Lingayen, Pangasinan ) S.S.

AFFIDAVIT OF KINSHIP

I, _________________, of legal age, single and a resident of

________________________, after having been sworn in accordance
with law do hereby depose and state that:

1. I am the son of the late ______________ who died on

______________ at __________________________;

2. I am the only representative or kin entitled to claim the benefits

pertaining to her membership in the Senior Citizen’s Association
of _________________;

3. I am executing this Affidavit to attest to the truth of the foregoing

declarations and for all intents and purposes this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 30 th

day of _________________________.

Affiant

SUBSCRIBED AND SWORN to before me this

_______________________ by the affiant who is personally known to
me to be the same person who executed the foregoing instrument.

WITNESS MY HAND AND SEAL.

Doc. No.___;
Page No.___;
Book No.___;
Series of 2022.