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SSSForm_Affidavit_Death_Claim_Benefits-converted

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20 views2 pages

SSSForm_Affidavit_Death_Claim_Benefits-converted

Uploaded by

Cost Accounting
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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REPUBLIC OF THE PHILIPPINES)

City/Municipality of_____________) S.S. SSS FORM CLD - I.3


_______________________________) A
Province of ____________________)

AFFIDAVIT FOR DEATH BENEFIT


CLAIM
I, Imelda V. Silvestre , of legal age, single/married and presently residing at
Blk 8 Lot 14 Northville 2, Bignay Valenzuela City having been sworn according
to law, depose and say: That I am the W i f e of the late, P a t e r n o A .
S i l v e s t r e J r . who died at NKTI East Avenue, Quezon City , on September
29, 2021 .
That the names and pertinent data of the aforementioned deceased member’s
immediate relatives and next to kin are as follows:
LEGITIMATE HUSBAND/WIFE DATE & PLACE OF ADDRESS
MARRIAGE (if dead, give date and place
Imelda Villaruel Silvestre
of death instead)

COMMON-LAW HUSBAND/WIFE DATE OF UNION ADDRESS


(if dead, give date and place
of death instead)

LEGITIMATE/LEGITIMATED/ DATE/PLACE OF BIRTH (if minor, give name, address and


LEGALLY ADOPTED relationship of guardian)
CHILDREN

LLEGITIMATE CHILDREN DATE/PLACE OF BIRTH ADDRESS

MOTHER/ ADDRESS
FATHER (if dead, give date and place of death
instead)
LEGALLY
MARRIED? YES
NO
That affiant further certify that the documents establishing the fact/s of
__________________ such as the ______________________ could not be submitted for the
following reasons: __________________________________________________________________
FURTHER, AFFIANT SAYETH NAUGHT.

AFFIANT

SUBSSRIBED AND SWORN TO before me this _____ day of___, 20 __ affiant


having exhibited to me his/her Res. Cert. No. A- _____________ issued at ________________
__________________ on________________, 20 __.
NOTARY PUBLIC
Until
DOC NO.: ______________________

PAGE NO.: -------------------------------

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