Republic of the Philippines )

Province of Zambales ) S. S.
Municipality of Iba )
AFFIDAVIT OF EXPENSES
I, __________________., of legal age, Filipino and a resident of rgy.
!!!!!!!!!!!!!!!!!!!!!!, after having been duly s"orn to, in accordance "ith
la", do hereby depose and say that#
$.) I am the son of the late ______________ "ho died last
!!!!!!!!!!!!!!!! %&$&'
%.) ecause of his death, I incurred the follo"ing e(penses'
%.$ ) Funeral Services and *as+et , P $$,&&&.&&
%.% ) -omb .(penses , P /,&&&.&&
0cement, steel bars, sand, etc.)
%./ ) 1a+e and miscellaneous e(penses , P 2,&&&.&&
0groceries, meat, food and drin+s)
!!!!!!!!!!!!!!!!!!
3R456 -7-48 , P %&,&&&.&&
/.) 6uring his lifetime, my father, ___________________, is a
bonafide member of the Social Security System having her SSS 5o.
!!!!!!!!!!!!!!!!!'
9.) I am e(ecuting this affidavit to attest to the truth of all the
foregoing facts and for the purpose of applying for "hatever burial
benefits I may have in connection "ith my father:s death and for
"hatever legal purpose this may serve.
I further sayeth naught.
I5 1I-5.SS 1;.R.7F, I have hereunto set my hand this <
th
day of
7ctober %&$& at Iba, Zambales.
_________________________
4ffiant

S=S*RI.6 456 S17R5 to before me this
6oc. 5o. !!!!
Page 5o. !!!!
oo+ 5o. !!!!
Series of %&$&.