RET-01224 (12-2015)

REPUBLIC OF THE PHILIPPINES )S.S.

CITY OF QUEZON )

AFFIDAVIT
(Funeral Expense)

I, _____________________, legal age, single/Married, Filipino and presently residing at

_____________________ after having been duly sworn in accordance with law hereby depose and say:

1. That I personally know the fact of death of the deceased, _____(name of

deceased)________, who died at __________________, on _______________ because
he/she was my ___________________;
2. That the deceased was a member of the Social Security System with SS Number
_______________ and covered under his/her last employer ____________________ with
business address at _________________________________________;
3. That as ______________________, I actually paid his/her funeral expenses in the amount of
P___________________, broken as follows:

a. Materials for coffin/cremation P________________

b. Interment/Transportation services P ________________
c. Food and other miscellaneous expenses during the wake P_________________
d. Others (specify) P ________________
Total: P ____________________

4. That I am executing this affidavit to attest to the truth of the foregoing statements and to
support my claim for SSS benefit, in the absence/unavailability of the Official Receipts for
funeral expenses.

FURTHER, affiant sayeth none.

_______________________________
Signature over Printed Name of Affiant

SUBSCRIBED AND SWORN TO before me this _____ day 20___ at Quezon City, Philippines,
affiant having exhibited to me his/her two (2) valid Identification Cards ______________ &
____________ bearing his/her picture and signature as competent evidence of identity.

_______________________________
NOTARY PUBLIC

Doc No. _____________:

Page No. ____________:
Book No. ____________:
Series of 2016.
RET-01224 (12-2015)