REPUBLIC OF THE PHILIPPINES }

CITY AND PROVINCE OF ILOILO } S.S.

X-----------------------X

AFFIDAVIT
(SURVIVING LEGAL SPOUSE DID NOT PAY FOR FUNERAL EXPENSES)

TO WHOM THIS MAY CONCERN:

I, MA. MAXIMA HERVIAS y CADARIN, of legal age, Filipino, single,

resident of Brgy. Sto. Angel, San Miguel, Iloilo, and is not the named payee
in the herein receipt for expenses that was incurred in the burial/cremation
of the deceased SSS member namely: ROMMEL VILLEGAS HERVIAS
(Decedent) with SSS NO. 07-2044173-2.

EXPENSES ISSUING COMPANY / AMOUNT IN RECEIPT

FUNERAL HUALDE FUNERAL SERVICES / PhP 57,000.00
EXPENSES

That I, the SURVIVING SPOUSE, did not pay for the funeral expenses.

IN WITNESS WHEREOF, I have hereunto set my hand this 7 February 2024.

MA. MAXIMA HERVIAS y CADARIN

Brgy/Resident ID. 011-028-078

SUBSCRIBED AND SWORN to before me, a notary public for and the
above jurisdiction, on the date and place above-stated.

Doc. No.: ___;

Page No.: ___;
Book No.: ___;
Series 2024.