SWORN AFFIDAVIT CONFIRMING DEPENDENCY OF

PARENT OR PARENT-IN-LAW
Member/Policy holder Number:
I,

(member/policy holders name), the undersigned,

Date of birth / ID / Passport No.

of

(address),

hereby declare the following in respect of my parent/parent in-law

(beneficiarys name),
Date of birth / ID / Passport No.

1. Financially dependent on me for care and support

Thus declared on this

day of

20

Signed:

PLEASE ENSURE THIS FORM IS SIGNED AND STAMPED BY A COMMISSIONER OF OATHS IN THE BLOCK
PROVIDED BELOW

STAMP AND SIGNATURE BY

COMMISSIONER
OF OATHS