REPUBLIC OF THE PHILIPPINES)

IN THE CITY OF ) SS.

X---------------------X

AFFIDAVIT OF WAIVER OF CLAIMS

I, AAA, Filipino, of legal age, widower and a resident of City , Philippines,

after having been sworn in accordance with law, upon my oath do hereby state:

1. That I am the surviving spouse of the late EEE who died on ________ at
________ City;

2. That my deceased wife was a GSIS member;

3. That the official receipts for the interment and burial expenses of my late
wife were issued in the name of one of our children namely CCC and I would
like my daughter CCC to claim and process the GSIS benefits of EEE;

4. That I am waiving my rights and claims and whatever GSIS benefits

that I may receive in favor of my daughter CCC;

5. I am executing this affidavit to attest to the truth of the foregoing facts and
for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ___________at

_________ City, Philippines.

AAA
Affiant

SUBSCRIBED AND SWORN to before me this _____________ at Davao City,

Philippines, with affiant exhibiting to me his Professional Driver’s License with Nos.
____, a competent proof of his identity.

Doc. No. ______ ;

Page No. ______;
Book No. ______;
Series of 2021.