Republic of the Philippines}

Quezon City, Metro Manila} S.S.

AFFIDAVIT OF CIRCUMSTANCES OF DEATH

I, _________________________________, Filipino, of legal age, married/single,

residing at _________________________________, Bgy _______________________,
Quezon City, after having been duly sworn in accordance with law, hereby depose and
say:

1. That I am the __________________ of the late _____________________

who died last ________________________ at our residence located in the
same address as above;

2. That to the best of my knowledge and belief, the above person died of
____________________________________ and there was no foul play
connected with his/her death thereof I am not filing any case or claim against
anyone;

3. That it is my wish that I be issued a certificate of death of the above person by

the proper government authority;

4. That I executed this affidavit to attest to the truth and veracity of the foregoing
facts and not for FRAUD and for whatever legal purpose it may serve.

AFFIANT FURTHER SAYS NONE.

IN WITNESS WHEREOF, I have hereunto set my hand this ______________ at

Quezon City, Metro Manila, Philippines.

__________________________
Affiant
CTC No ___________________
Issued on __________________
Issued at Quezon City

SUBSCRIBED AND SWORN to before me on the date and place above

indicated. Affiant exhibiting to me his/her Community Tax Certificate as indicated
above.

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Series of 2010