REPUBLIC OF THE PHILIPPINES )

PROVINCE OF LAGUNA ) S.S.

MUNICIPALITY OF LOS BAÑOS )
X---------------------------------------------------X

AFFIDAVIT

I, (Pangalan po ng mother nyo), of legal age, married, Filipino citizen, and with
office address at__________________, after having been duly sworn in accordance
with law, hereby depose and say:

1. That I am the surviving spouse of the late (Pangalan po ng father nyo),who died
last_______________ at___________;

2. That I am among those who facilitated the funeral and burial of my husband
hence, there are some official receipts issued in my name;

3. That the one who spent for the funeral and burial of my husband was my son,
(Name nyo po ms Rr);

4. That it is for this reason that I am WAIVING all my rights and interests over
any amount due in relation to the funeral and burial expenses in favor of
(pangalan nyo po ms rr), particularly the SSS benefits of my husband, being a
member thereof;

5. That I executed this affidavit to attest to the truth of the foregoing and for
whatever legal purpose it may serve

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of

_____________ in Los Baños, Laguna, Philippines.

Name ng mother nyo po

Affiant

SUBSCRIBED AND SWORN to before me, this ____ day of __________ 20____, in the
Municipality of Los Baños, Laguna, Philippines.

WITNESS MY HAND AND NOTARIAL SEAL…

Doc. No. ______;

Page No. ______;
Book No. ______;
Series of 2024.