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Affidavit For Death Benefit Claim: Legitimate/ Legitimated

This document is an affidavit for a death benefit claim filed with the Social Security System of the Philippines. It provides information about the deceased member, including the claimant's relationship to the deceased. It lists the deceased member's spouse, children, parents and their addresses. It also states that documents establishing facts about the deceased cannot be submitted and is signed and notarized.

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816 views1 page

Affidavit For Death Benefit Claim: Legitimate/ Legitimated

This document is an affidavit for a death benefit claim filed with the Social Security System of the Philippines. It provides information about the deceased member, including the claimant's relationship to the deceased. It lists the deceased member's spouse, children, parents and their addresses. It also states that documents establishing facts about the deceased cannot be submitted and is signed and notarized.

Uploaded by

srozaragoza
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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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:
That I am the __________ of the late ____________________ , who died 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

MOTHER/FATHER ADDRESS
(if dead, give date and place of death instead)
LEGALLY MARRIED?
YES NO

That affiant further certify that the documents establishing the fact/s of
__________________ 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.: ______________________

PAGE NO.: -------------------------------

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