Vous êtes sur la page 1sur 4

AFFIDAVIT OF DEATH FOR INSURANCE CLAIM

I, Izzeah Ramos, of legal age, Filipino citizen, widow and presently


residing at 17E2, University Tower, Pedro Gil, Malate, Manila, after having
been duly sworn to in accordance with law, do hereby depose and say:

1. That I am the widow of Luke Robert Hemmings who died on November 30,
2016 in Quezon City because of head injuries sustained in a vehicular
accident as per autopsy result conducted by Dr. Derek R. Sheperd;

2. That per investigation of the Quezon City Police Station, my husband was
driving along the northbound lane of EDSA in front of Camp Aguinaldo in
Quezon City when he was hit by a truck coming from the opposite direction;
copy of the Traffic Investigation Report is hereto attached as Annex "A";

3. That at the time of the incident, my husband was a duly licensed driver
carrying Driver's License No. 123456 and was riding on a Toyota Fortuner,
gray in color and with Plate No. XYZ-123 owned by me with Certificate of
Registration No. 55667788;

4. That I am executing this affidavit in support of my application for insurance


claim with _____________, to attest to the truth of the foregoing, and for
whatever legal purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 3rd day


of December 2016 at Manila City, Philippines.

Izzeah Ramos
Affiant

SUBSCRIBED AND SWORN to before me this 3rd day of


December 2016 in the City of Makati, Philippines, affiant exhibiting to
me her competent evidence of identity by way of Philippine Passport No.
12344 issued at Manila, Philippines on September 24, 2016.

Doc No. : _____


Page No.: ______
Book No.: ______
Series of 2016

JOINT AFFIDAVIT OF COHABITATION


We, Angelina Jolie and Brad Pitt, both of legal age, Filipino, single
(living together) and residents of, Lot 5, Block 19, City Homes Subd., City
of Ilagam, Isabela, after having been duly sworn to in accordance with law,
state THAT:

1. We have been living together as husband and wife under the same roof,
continuously and without any interruption, since February 14, 2010;

2. During our cohabitation and even until the present, we remain both of single
status and, hence, there exists no legal impediment for us to marry each
other;

3. We were blessed with one son named Maddox Pitt who was born on August
29, 2010 in St. Lukes Medical Center in Taguig;

4. We are executing this affidavit to attest to the foregoing facts and for the
purposes of contracting marriage without the need of securing the marriage
license pursuant to the provisions of Article 34 of the Family Code of the
Philippines.

IN WITNESS WHEREOF, we have hereunto set our hands


this February 14, 2016 in City of Ilagan, Isabela, Philippines.

Angelina Jolie

Brad Pitt

Affiant

Affiant

SSS ID No. 123456

GSIS ID No. 78910_

SUBCRIBED AND SWORN TO before me this March 13, 2016 in


Ilagan City, Isabela, Philippines, affiants exhibiting to me their valid proofs
of identification.

Doc. No. _____;


Page No. _____;
Book No. _____;
Series of 2016.