REPUBLIC OF THE PHILIPPINES….

)
PROVINCE OF NEGROS ORIENTAL) S.S.
DUMAGUETE CITY …………………. )

AFFIDAVIT OF HEIRSHIP WITH UNDERTAKING

I, CRISPIN ZAMORA NOBLE, of legal age, Filipino, single with residence and postal
address at Purok Bala-anong Tubig, Barangay Banilad, Dumaguete City, Negros Oriental,
Philippines, after having sworn to in accordance with the laws hereby depose and say THAT:

1. I am one of the heirs of the late Anastacia Zamora Noble, my mother, who died intestate
and without debts on 12 June 2019 at Dumaguete City, Negros Oriental;

2. During her lifetime she was a registered member of the Office of the Senior Citizen Affair,
Dumaguete City. As such, she is entitled to its benefits and making the heirs of the
deceased as beneficiary of whatever the registered member is entitled for;

3. The deceased left no known debts which are not settled up to now and I hereby adjudicate
unto myself the death benefits of my late mother as one of her surviving and compulsory
heir who took good care of her until her death;

4. I waived and released the City Social Welfare and Development Office, Dumaguete City,
under the Department of Social Welfare and Development (DSWD) and its
representative/s from any and all claims, responsibilities, actions, liabilities, compensation
or damages which may have arisen or may arise resulting from or any manner connected
with my claim of the death benefits as beneficiary of my late mother Anastacia Zamora
Noble;

5. That I agree to exclude City Social Welfare and Development Office, Dumaguete City,
under the Department of Social Welfare and Development (DSWD) for any and all claims
and/or liabilities to any other person, party or entity, with respect to any matter involving
to my claim;

6. I am executing this affidavit of heirship with undertaking to prove the veracity of the
foregoing facts.

IN WITNESS WHEREOF, I hereunto set my hand this _________ in Dumaguete City,

Philippines.

CRISPIN ZAMORA NOBLE

Affiant
Driver’s License No. G02-84-007982

SUBSCRIBED AND SWORN to before me this ___________ in Dumaguete City,

Philippines.
Doc. No. ____;
Page No. ____;
Book No. ____;
Series of 2019.