Republic of the Philippines )

City of Cagayan de Oro ) S.S.

AFFIDAVIT

I, X, Filipino, 66 years old, married and a resident of Mambayaan Balingasag,

Misamis Oriental, after having been duly sworn to in accordance with law, do hereby
depose and say:

1. That my husband y died on February 2, 2015;

2. That I am the sole beneficiary of the SSS death claims of my deceased husband;
3. That a Birth Certificate is a necessary requirement for the release of my claim;
4. That upon requesting a copy of my Birth Certificate from NSO, the office issued a CERTIFICATE
OF NO RECORD;
5. That I immediately process my late registration at the LCR Camiguin;
6. That it takes almost two years for the release of my Birth Certificate, specifically last March
2017;
7. That I did not intend to delay the process of my SSS death claim application;
8. That I am executing this affidavit to attest to the truth of the foregoing, to explain the
delay of the above facts.

IN WITNESS WHEREOF, I have hereunto set my hand this 21st day of June 2017
at Cagayan de Oro City, Philippines.

x
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, this 21 st day of the June 2017 at
Cagayan de Oro City, Philippines.