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philhealth4

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for retirement and health

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									REPUBLIC OF THE PHILIPPINES )                                                                                               SSS FORM CLD - 1.3 A
City / Municipality of ___________ ) S.S.
_______________________________ )
Province of ____________________)



                                         AFFIDAVIT FOR DEATH BENEFIT CLAIM
              I, ________________, of legal age, single/married and presently residing at
        _______________________________ having been sworn according to law, depose and say:
              T h a t I a m t h e _ _ _ _ _ _ _ _ _ _ o f t h e l at e _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ , w h o d i e d at
        ____________________________ on _____________________________________.
              That the names and pertinent data of the aforementioned deceased member’s
        immediate relatives and next to kin are as follows:
LEGITIMATE HUSBAND/WIFE                     DATE & PLACE OF MARRIAGE                                             ADDRESS
                                                                                                          (if dead, give date and place of
                                                                                                                   death instead)

COMMON-LAW HUSBAND/WIFE                                            DATE OF UNION                                        ADDRESS
                                                                                                           (if dead, give date and place of
                                                                                                                    death instead)

LEGITIMATE/ LEGITIMATED/                                     DATE/ PLACE OF BIRTH                        (if minor, give name, address and
LEGALLY ADOPTED CHILDREN
                                                                                                              relationship of guardian)




ILLEGITIMATE CHILDREN                                        DATE/ PLACE OF BIRTH                                     ADDRESS




                                                                                    ADDRESS
              MOTHER/FATHER                                  (if dead, give date and place of death instead)
                                                                                                                            LEGALLY MARRIED?
                                                                                                                             YES     NO
                   Th at a f f i a n t f u r t h e r c e r t i f y t h at t h e d o c u m e n t s e s t abl i s h i n g t h e fa c t / s o f
            __________________ such as the ______________________ could not be submitted for the
            following reasons: __________________________________________________________________
                   FURTHER, AFFIANT SAYETH NAUGHT.


                                                                                                                AFFIANT


                   SUBSCRIBED AND SWORN TO before me this _____ day of __________, 20 __ affiant
            having exhibited to me his/her Res. Cert. No. A- _____________ issued at ________________
            __________________ on _____________, 20 __.

                                                                                                 NOTARY PUBLIC
                                                                                                 Until_______________________
DOC NO.: ______________________

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