Republic of the Philippines...

)
Quezon City.........................)

AFFIDAVIT OF LIABILITY
I, ______________________________, Filipino, of legal age and with residence at
________________________________________, after having been duly sworn to in accordance with
law, do hereby depose and state that:
1. My___________________, ____________________________was an active member
Relationship to Deceased

Name of Deceased

of the Mutual Aid System (MAS) Plan _2_ of the Philippine Public School Teachers
Association (PPSTA) at the time of his/her death on ______________ ;
Date of Death

2. I am one of the beneficiaries of ___________________________in his/her PPSTA MAS;

Name of Deceased

3. Considering the measly amount of the death benefit from PPSTA of

___________________________ and upon my request as well as prior approval of my coName of Deceased

beneficiaries, PPSTA entrusted to me the said death benefit in full;

4. I assume full and release PPSTA of responsibility and liability should my co-beneficiary/ies or
his/her/their authorized representative/s or agent/s file a separate claim before PPSTA for
the release of his/her/their share/s in death benefit from the aforesaid Association
of__________________________and
Name of Deceased

5. I am executing this affidavit to attest to the veracity of the facts above-stated and for
whatever legal purpose this may serve.
IN WITNESS WHEREOF, I have hereunto set my hand this ____th day of _________________,
2012 at Quezon City, Philippines.
______________________________
Signature Over Printed Name of Affiant-Claimant
CTC No. _____________________
Issued at ____________________
Issued on ____________________

SUBSCRIBED AND SWORN to before me this ___th day of ___________________, 2012 at

Quezon City, Philippines.
NOTARY PUBLIC
Doc. No. __________;
Page No. __________;
Book No. __________;
Series of 2012

PHILIPPINE PUBLIC SCHOOL TEACHERS ASSOCIATION

245 Banawe St., Quezon City

INFORMATION SHEET FOR BENEFICIARIES

(To be accomplished by Claimant/Beneficiary of Legal Age)

Name of Claimant/Beneficiary

2
3

Present Address
Date of Birth

4
5

Occupation
Name of Deceased Member

6
7

Cause of Death
Name of Parents of the Deceased :

8
9
10

(Indicate if parents are already deceased)

Your relationship with the deceased:
Name of surviving Husband/Wife of deceased:
State number and names of children of the deceased:

Age

Alive

Status

Place of Business/Employment
Date of death
Father
Mother

Date of Birth

Deceased

*If the space provided is not enough, please continue at the back.

11

State name of beneficiaries who are minors. (below 18 years old)

12

Minor children under the custody of their :

Father
Mother

I hereby certify that the foregoing facts are true and correct. Further, I understand that upon
receipt of the proceeds of this claim, the PPSTA shall be released and forever discharged from any
liability whatsoever arising from the membership of the deceased with PPSTA.

Thumbmarks
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Right

Beneficiary's Signature
ID Picture
Contact Number/s

E-mail address
*Please ensure that your signature in this form is
similar with your signature in the two (2) valid IDs
that you will submit.