REPUBLIC OF THE PHILIPPINES )

CITY OF QUEZON CITY ) S.S.

AFFIDAVIT FOR DEATH BENEFIT CLAIM

I, BLANCHE KHAYLIL P. DE LA CUESTA , of legal age, single and

presently residing at 34 Alley 3 corner Road 6, Project 6, Quezon City , having been
sworn according to law, deposes and says:

That I am the granddaughter of the late GLORIA C. RUEDA , who

died at EAST AVENUE MEDICAL CENTER on JANUARY 15, 2015 .

That the names and pertinent data of the aforementioned deceased member’s
immediate relatives and next to kin are as follows:

LEGITIMATE DATE & PLACE OF ADDRESS (if dead, give

HUSBAND/WIFE MARRIAGE date and place of death
instead)
Dean Rueda May 15, 1966 34 Alley 3 cor. Rd 6, Proj. 6
COMMON-LAW DATE OF UNION ADDRESS (if dead, give
HUSBAND/WIFE N/A date and place of death
N/A instead)
LEGITIMATE/ DATE/ PLACE OF (if minor, give name,
LEGITIMATED/LEGALL BIRTH address and relationship
Y ADOPTED CHILDREN of guardian)
Ronald L. dela Cuesta February 28, 1967/ N/A
Quezon City
ILLEGITIMATE DATE/ PLACE OF ADDRESS
CHILDREN BIRTH
N/A N/A N/A
MOTHER/FATHER ADDRESS (if dead, give
date and place of death
instead)
Salome de la Cuesta June 21, 1991 LEGALLY MARRIED?
Pedro de la Cuesta Feb 16, 1987 YES

That affiant further certify that the documents establishing the fact/s of
____________ such as the _________________ could not be submitted for the following
reasons: ____________________________________________________________________.
FURTHER, AFFIANT SAYETH NAUGHT.

BLANCHE KHAYLIL P. DE LA CUESTA

AFFIANT
SUBSCRIBED AND SWORN TO before me this _____ day of ______, 20__ affiant having
exhibited to me his/her Res. Cert. No. A- __________issued
at__________________________ on _______________, 20__.
NOTARY PUBLIC
Until____________
Doc. No.____;
Page No.____;
Book No.____;
Series No.____;