REPUBLIC OF THE PHILIPPINES )

PROVINCE OF SORSOGON ) Sc.

SORSOGON CITY )

AFFIDAVIT
I, RAMON M. LACUPANTO JR., of legal age, Filipino, married
and a resident of Purok 4, Barayong, Sorsogon City after having been sworn
to in accordance with law do hereby depose and state:

1. That I am the above affiant;

2. That I am the brother and legal heir of SALVADOR M.

LACUPANTO who died on December 27, 2019 at Bicol Regional
Training and Teaching Hospital (BRTTH), Legazpi City;

3. That during the lifetime of my brother, he was a member of Social

Security (SSS) and made contributions thereto;

4. That I was the one who spent for his burial as evidenced by the
receipts for the funeral services;

5. That I am executing this affidavit in order to attest to the veracity

of the foregoing statements and to affirm that the same are true and
correct to the best of my knowledge and belief, specifically to
support my claim for burial and death benefits from SSS, and for
all legal intents and purposes this may serve;

IN WITNESS WHEREOF, I have hereunto set my hand this 26th

day of June, 2020 in Sorsogon City.

RAMON M. LACUPANTO JR.

Affiant

SUBSCRIBED AND SWORN to before me this 26th day of June,

2020 in Sorsogon City.