REPUBLIC OF THE PHILIPPINES)

PROVINCE OF TARLAC : S.S.

MUNICIPALITY OF BAMBAN )

AFFIDAVIT
I, _____________________________, of legal age, Filipino, with residence and
postal address at __________________________________________________________, after
having been duly sworn to in accordance with law, do hereby depose and say:

THAT—

1. I am the surviving wife of the late _____________________________, who

died on _____________________________ at
__________________________________________________________, copy of
his Certificate of Death is attached as Annex “A” to form an integral part
hereof;

2. During our union as husband and wife, we were blessed of three (3) children
namely: _____________________________, _____________________________
and _____________________________, copies of their Certificate of Live
Birth are attached as Annexes “B”, “C” and “D” to form an integral part
hereof;

3. I am executing this Affidavit to attest to the truth of all the foregoing; to

attest under oath that we are the only surviving legal heirs of the late
_____________________________; and to support my Application for
MRI/SRI Claim at PAG-IBIG and for whatever legal purposes it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

_____________________________ at Bamban, Tarlac, Philippines.

_____________________________
Affiant
ID No. _______________________
Valid Until: ___________________

SUBSCRIBED AND SWORN to before me this

_____________________________ at Bamban, Tarlac, Philippines.

WITNESS MY HAND AND SEAL.

Doc. No. _____;

Page No. _____;
Book No. ____;
Series of 2020.