Republic of the Philippines)

)
)…s.s.

AFFIDAVIT OF CONFIRMATION

I, _____________________________, a Filipino of legal age, a resident

of_______________________________________, a bona fide member of the Philippine National Police
(PNP) with the rank of _____________ and presently assigned at __________________ after having
been duly sworn to in accordance with law, do hereby depose and says that:

1. Pursuant to this affidavit, I am confirming that the following are my legal

beneficiaries and/ or heirs, to wit:

NAME RELATIONSHIP BIRTH DATE

_____________________ ________________ _____________

_____________________ ________________ _____________

_____________________ ________________ _____________

_____________________ ________________ _____________

2. My relationship with person whose names are listed above are borne out by the fact
that I am the lawful spouse and the legitimate/illegitimate father of the afore-named children as
evidenced by the attached advisory on marriages, marriage contract and birth certificates:

3. That, listed below are my children who were previously included in my Certificate of
Legal Beneficiaries (CLB) database to which I am requesting for their exclusion from the list of CLB
for the reason of having their own family and of reaching their legal age to wit:

NAME RELATIONSHIP BIRTHDATE

_____________________ ________________ _____________

_____________________ ________________ _____________

_____________________ ________________ _____________

_____________________ ________________ _____________

4. That, I hold myself criminally and administratively liable for perjury and dishonesty
should any statements made herein are inaccurate or later found to be false and in of law.

AFFIANT SAYETH NAUGHT:

__________________________
Affiant

Contact No: ____________

SUBSCRIBED AND SWORN to before me this _____ day of _______________ at

__________________ Philippines.

Doc No. _____

Page No. _____
Book No. _____
Series No. _____