Transcription of affidavit for death benefit claim - sss.gov.ph
1 REPUBLIC OF THE PHILIPPINES )City / Municipality of _____ ) )Province of _____)SSS FORM CLD - AAFFIDAVIT FOR death benefit CLAIMI, _____, of legal age, single/married and presently residing at_____ having been sworn according to law, depose and say:That I am the _____ of the late _____, who died at_____ on the names and pertinent data of the aforementioned deceased member simmediate relatives and next to kin are as follows:LEGITIMATE HUSBAND/WIFEDATE & PLACE OF MARRIAGEADDRESS(if dead, give date and place ofdeath instead)COMMON-LAW HUSBAND/WIFEDATE OF UNIONADDRESS(if dead, give date and place ofdeath instead)LEGITIMATE/ LEGITIMATED/LEGALLY ADOPTED CHILDRENDATE/ PLACE OF BIRTH(if minor, give name, address andrelationship of guardian)ILLEGITIMATE CHILDRENDATE/ PLACE OF BIRTHADDRESSMOTHER/FATHERADDRESS(if dead, give date and place of death instead)That affiant further certify that the documents establishing the fact/s of_____ such as the _____ could not be submitted for thefollowing reasons: _____FURTHER, AFFIANT SAYETH AND SWORN TO before me this _____ day of _____, 20 __ affianthaving exhibited to me his/her Res.
2 Cert. No. A- _____ issued at _____ on _____, 20 PUBLICU ntil_____DOC NO.: _____PAGE NO.: -------------------------------AFFIANTLE GALLY MARRIED?YESNO
