REPUBLIC OF THE PHILIPPINES )

S.S.

AFFIDAVIT OF SURVIVAL HEIRS

WE, ______________________, of legal age, widow and a resident of
_______________________________________ and ______________________, likewise of
legal age, married and a resident of _______________________________________, after being
sworn in accordance with law, hereby depose and say:
1. That we are the legitimate children and sole heirs of the late
_____________________________ who died on March 7, 2010 at Gapan City,
Nueva Ecija;
2. That being the sole heirs, we hereby agree for and in our behalf to be represented by
_____________________________ in claiming whatever benefits due to us as
surviving heirs of the late _____________________________;
3. That this representation covers and or includes her savings account in Producers Bank
and all other money claims from government corporation and other insurance
institutions;
4. That this authority is hereby given to _____________________________ for
reference and guidance; and
5. That we are executing this affidavit to attest to the truth of the foregoing statement
and circumstances to satisfy the inquiry of any person or office.
IN WITNESS WHEREOF, we have hereunto affixed our signatures this 27 th day of
October 2010 at Taytay, Rizal.

Affiant

Affiant

SUBSCRIBED AND SWORN to before me, this 27 th day of October, 2010 at Taytay,
Rizal _____________________________ exhibiting to me her Social Security System I.D. with
No. _____________________________ issued by SSS Quezon City and Postal I.D. with No.
_____________________________ valid until 9-23-2013 issued at Taytay, Rizal and
_____________________________exhibiting to me his Social Security System I.D. with No.
_____________________________issued by SSS Quezon City and Professional Regulations
Commission issued on 1-5-2009 at Manila.

NOTARY PUBLIC
Doc No. _____
Page No. _____
Book No. _____
Series of 2010