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 NON-UNIFORMED PERSONNEL presently assigned at ORCADD, PRO3,
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 heirs, to wit:

NAME RELATIONSHIP BIRTH DATE

JUANA DOE DELA CRUZ WIFE JAN. 01, 1985
JOAN DOE DELA CRUZ DAUGTHER FEB 01, 2013
JOAN DOE DELA CRUZ DAUGTHER FEB 01, 2013

2. My relationship with persons whose names are listed above are borne out by
the fact that I am the lawful spouse and the father of the afore-mentioned
children as evidenced by the attached advisory on marriages, marriage contract
and birth certificates;

3. That all the documents I have attached and submitted to support the updating
of my Declared Legal Beneficiaries 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 of law.

AFFIANT SAYETH NAUGHT:

Signature PNPPersonnel
Affiant
Contact No: 0912-456-5789

SUBSCRIBED AND SWORN to before me this day of at

, Philippines.

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