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Affidavit For Claiming Refund On Funeral Expenses

This document is an affidavit for refund of funeral expenses from the Government Service Insurance System (GSIS) in the Philippines. It requires the claimant to provide details of their relationship to the deceased, the date and cause of death, and a list of expenses incurred for the burial. Witnesses must also corroborate the claimant's statements. The claimant and witnesses must then sign and have the document notarized.

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Lecel Llamedo
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993 views

Affidavit For Claiming Refund On Funeral Expenses

This document is an affidavit for refund of funeral expenses from the Government Service Insurance System (GSIS) in the Philippines. It requires the claimant to provide details of their relationship to the deceased, the date and cause of death, and a list of expenses incurred for the burial. Witnesses must also corroborate the claimant's statements. The claimant and witnesses must then sign and have the document notarized.

Uploaded by

Lecel Llamedo
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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GSIS Form No.

FUNERAL-2011-04-001 11-04-001

PASEGURUHAN NG MGA NAGLILINGKOD SA PAMAHALAAN (GOVERNMENT SERVICE INSURANCE SYSTEM) Financial Center, Pasay City, Metro Manila 1308

REPUBLIC OF THE PHILIPPINES) ) S. S. -------------------------------------)

Affidavit for Refund of Funeral Expenses


This Affidavit is to be executed if the claimant is other than the surviving spouse. I, ____________________________________________________________________, of legal age, married/single and residing at ___________________________________________, after having sworn in accordance with law, hereby depose and state: 1. That I am the ________________ of the late ______________________________________, who was insured in the Government Service Insurance System and died on _______________________________; 2. That I took charge in the interment of the above-mentioned deceased member and as such I was responsible for the burial expenses incidental thereto; 3. That the following burial expenses were incurred in the interment of the deceased: Funeral service Cemetery lot Burial permit Coffin Music Food & Drinks Church rites Tomb Miscellaneous TOTAL P P

(served to the people who came to condole with the bereaved family)

_____________________________________ Affiant

CORROBORATION
We, the undersigned, Filipinos, of legal age and with postal address indicated below our signatures, after having duly sworn to in accordance with law depose and say: That having personal knowledge of the facts of the death of the insured Mr./Mrs./Ms._____________________________________________, confirm the truth of the statements made herein by claimant/affiant. who died on ______________________ at ___________________________________, do hereby declare and

___________________________________ Signature of Witness Address: ________________________________________

___________________________________ Signature of Witness Address: _______________________________________

Subscribed and sworn to before me this _______ day of _________________, 20___ in the city of Pasay, Philippines, affiant(s)/witness(es) exhibiting to me, respectively, their Community Tax Certificates and the following valid government identifications: Name CTC No. Place of Issue Date Issued

NOTARY PUBLIC
Doc. No. _________ Page No.__________ Book No.__________ Series of 201______ Expiry date: December 31, _______

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