Republic of the Philippines )

City/Municipality of PROSPERIDAD ) S.S.

A F F I D A V I T

I, JEURDECEL CASTRO MARTIZANO, of legal age, married, Filipino, and presently residing at Prosperidad, Agusan del Sur,
after having been duly sworn in accordance with law hereby depose and say:

1. That I know the fact of death of ARACELI LABORADA CASTRO who died at BUTUAN DOCTORS HOSPITAL, BUTUAN
CITY on SEPTEMBER 13, 2013 because she is my MOTHER.
2. That the deceased is a member of the Social Security System with SS No. 08-03643960-0 covered under
VOLUNTARY MEMBERSHIP.
3. That as DAUGHTER, I actually defrayed her funeral expenses in the amount of PhP 61, 742.00 broken down as
follows:

a.) Material for coffin P 37,900.00
b.) Food & misc. Expenses during the wake P 14,724.00
c.) Night prayer expenses P 2, 500.00
d.) Church Rites P 6, 618.00
TOTAL P 61, 742.00
4. That I am executing this affidavit to support my claim for funeral benefit which I am filing with the SSS.

FURTHER, affiant sayeth none.


JEURDECEL C. MARTIZANO
Affiant

C O R R O B O R A T I O N

We, JOCELYN S. MISA, residing at Poblacion, Prosperidad, Agusan del Sur and JOVELYN D. LAZONA, residing at
Poblacion, Prosperidad, Agusan del Sur both of legal age, single, hereby confirm the foregoing statements of Mrs.
Jeurdecel Castro Martizano to be true and correct based on our personal knowledge. Further, we bind ourselves
solidarily to reimburse the SSS the full amount of this funeral benefit in case an erroneous payment will be made by
virtue of this affidavit.


JOCELYN S. MISA JOVELYN D. LAZONA
Affiant Affiant

SUBSCRIBED AND SWORN before me this 14
th
day of April 2014, affiants exhibiting to me respectively their
Residence Certificated:

Res. No. 24635793 Issued at: MTO Prosperidad, Agusan del Sur
Res. No. 24652263 Issued at: MTO Rosario, Agusan del Sur



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NOTARY PUBLIC

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