SAMPLE: MARRIED

Republic of the Philippines)

)
)...s.s.

AFFIDAVIT OF CONFIRMATION

I, JUAN CRUZ DELA CRUZ, a Filipino of legal age, a resident of 123 ABCD ST.,
KAMUNING, QUEZON CITY, a bona fide member of the Philippine National Police with the rank
of Police Master Sergeant and presently assigned at DPRM, RMD after having been duly sworn
to in accordance with law, do hereby depose and says that:

1. Pursuant to this affidavit, I am confirming that the following are my legal beneficiary/ies
and/or heir/s, to wit:

NAME RELATIONSHIP BIRTHDATE

JUANA DOE DELA CRUZ WIFE JAN 01, 1985
JOAN DOE DELA CRUZ DAUGHTER FEB 01, 2013
JOHN DOE DELA CRUZ SON MAR 01, 2016

2. My relationship with person/s whose name/s is/are listed above is/are borne out by the fact
that I am the lawful spouse and the father/mother of the afore-mentioned child/children as
evidenced by the attached advisory on marriages, marriage contract and birth certificate/s;

3. That all the documents I have attached and submitted to support the updating of my Declared
Legal Beneficiary/ies are original copies obtained from Philippine Statistic Authority (PSA);
and

4. I hold myself criminally and administratively liable for perjury and dishonesty should any
statements made herein/documents submitted herewith are inaccurate or later found to be
false and in violation of law.

AFFIANT SAYETH NAUGHT:

Signature PNP Personnel

Affiant
Contact No.

SUBSCRIBED AND SWORN to before me this day of at

, Philippines

Doc. No.
Page No.
Book No.
Series No.
 SAMPLE: SOLO PARENT
Republic of the Philippines)
)
)...s.s.

AFFIDAVIT OF CONFIRMATION

I, JUAN CRUZ DELA CRUZ, a Filipino of legal age, a resident of 123 ABCD ST.,
KAMUNING, QUEZON CITY, a bona fide member of the Philippine National Police with the rank
of Police Master Sergeant and presently assigned at DPRM, RMD after having been duly sworn
to in accordance with law, do hereby depose and says that:

1. Pursuant to this affidavit, I am confirming that the following are my legal beneficiary/ies
and/or heir/s, to wit:

NAME RELATIONSHIP BIRTHDATE

JOAN DOE DELA CRUZ DAUGHTER FEB 01, 2013
JOHN DOE DELA CRUZ SON MAR 01, 2016

2. My relationship with person/s whose name/s is/are listed above is/are borne out by the fact
that I am the lawful father/mother of the afore-mentioned child/children as evidenced by the
attached cenomar and birth certificate/s;

3. That all the documents I have attached and submitted to support the updating of my Declared
Legal Beneficiary/ies are original copies obtained from Philippine Statistic Authority (PSA);
and

4. I hold myself criminally and administratively liable for perjury and dishonesty should any
statements made herein/documents submitted herewith are inaccurate or later found to be
false and in violation of law.

AFFIANT SAYETH NAUGHT:

Signature PNP Personnel

Affiant
Contact No.

SUBSCRIBED AND SWORN to before me this day of at

, Philippines

Doc. No.
Page No.
Book No.
Series No.
 SAMPLE: SINGLE

Republic of the Philippines)

)
)...s.s.

AFFIDAVIT OF CONFIRMATION

I, JUAN CRUZ DELA CRUZ, a Filipino of legal age, a resident of 123 ABCD ST.,
KAMUNING, QUEZON CITY, a bona fide member of the Philippine National Police with the rank
of Police Master Sergeant and presently assigned at DPRM, RMD after having been duly sworn
to in accordance with law, do hereby depose and says that:

1. Pursuant to this affidavit, I am confirming that the following are my legal beneficiary/ies
and/or heir/s, to wit:

NAME RELATIONSHIP BIRTHDATE

JOAN DOE DELA CRUZ MOTHER FEB 01, 1950
JOHN DOE DELA CRUZ FATHER MAR 01, 1952

2. My relationship with person/s whose name/s is/are listed above is/are borne out by the fact
that I am the lawful child of the afore-mentioned parent/s as evidenced by the attached
cenomar and birth certificate/s;

3. That all the documents I have attached and submitted to support the updating of my Declared
Legal Beneficiary/ies are original copies obtained from Philippine Statistic Authority (PSA);
and

4. I hold myself criminally and administratively liable for perjury and dishonesty should any
statements made herein/documents submitted herewith are inaccurate or later found to be
false and in violation of law.

AFFIANT SAYETH NAUGHT:

Signature PNP Personnel

Affiant
Contact No.

SUBSCRIBED AND SWORN to before me this day of at

, Philippines

Doc. No.
Page No.
Book No.
Series No.