(REPUBLIC OF THE PHILIPPINES)

) S.S

AFFIDAVIT OF CLAIM WITH WAIVER OF RIGHTS

We,______________________________________,____________________________________
____________________,________________________________________ ________________________
all of legal age, Filipino, residents of ______________________________________________________
________________________________ after having been duly sworn in accordnce with law, hereby
dispose and state, that;

1.We hereby declaire that we are the only surviving heirs of the deceased depositor ___________
_______________ who died on ______________, a copy of the Certificate of Death is here to attached as
ANNEX “A”. Likewise we further state under pain/penalty of perjury, punishable by imprisonment under
the Revised Penal Code, that we do not know any other heirs of the descent; further, descent does not
have any known debts or obligations unpaid of the time of his/her death;

2. At the time of his/her death; he/she left Saving Deposit Account/s with the Philippine Veterans
Bank- ___________________________ Branch under Savings Account No. ___________ with a
balance of P________________________.

3. A forestated deposit is the only property/ asset of the said deceased depositor;

4. We hereby request the Philippine Veterans Bank-_____________ Branch, to release the balance
of the said deposit account in his/her favor.

5.We hereby hold the Philippine Veterans Bank free and harmless from any claim/ suit that may be
brought against it by reason of the release of the said amount in favor of _____________________ ,and
we hereby undertake to indemnify the said bank in the event it suffers damages should any heir or creditor
subsequently claim deprivation of any rights by virtue of thids release and settlement.

FURTHER AFFIANT SAYETH NAUGHT.

_______________________________________
______________________________________
Affiant Affiant

Competent ID____________________________ Competent

ID____________________________
_______________________________________
______________________________________
Affiant Affiant

Competent ID____________________________ Competent

ID____________________________

_______________________________________
______________________________________
Affiant Affiant

Competent ID____________________________ Competent

ID____________________________

SUBSCRIBED AND SWORN before me on this _____________ day of 20___ Affiants

exhibiting to me their Community Tax Certificate numbers indicated under their names.

Doc. No.:____
Page No.:_____
Book No.:_____
Series of 2018