REPUBLIC OF THE PHILIPPINES)

__________________________ ) Sc.

AFFIDAVIT
I, XXX, of legal age, single, and with address at 143 Magandang Bahay, Makati City, a
under oath, state that:

1. I am the nephew of the late HHH, who died on March 22, 2015 at Palawan, and
who during his lifetime was a member of Social Security System (SSS);

2. The deceased was married to KKK;

3. The deceased and his wife have been in exclusive cohabitation and never
separated. They used to live at Rio Tuba, Bataraza,Palawan;

4. KKK is a legitimate dependent of the deceased and as of date, remains

unmarried.

5. I am executing this Affidavit to attest to the truth of the foregoing facts and for
whatever legal purposes it may serve.

IN WITNESS WHEREOF, I hereunto affix my signature this _________________ at

__________________________.

XXX
Affiant

Signed in the presence of:

_______________________________ ______________________________

JURAT

SUBSCRIBED AND SWORN to before me this _______________ at _____________, Affiant

exhibiting to me his Competent Identification Card: ______________________, issued on
_________________ at ________________.

NOTARY PUBLIC
Doc No. _______;
Page No. ______;
Book No. ______;
Series of 2019.