Republic of the Philippines)

City of Z A M B O A N G A) S.S.

AFFIDAVIT OF NEXT OF KIN

The undersigned, being first duly sworn, deposes and says:

1. That I am the next of kin of _______________________________, who died on or about the

______day of ______________________, 20_____.

2. That the decedent did not leave a surviving spouse

3. That no personal representative has been appointed for the decedent’s estate in this
state or elsewhere and no application for such an appointment is pending in this state or
elsewhere.

4. That this affidavit is made in support of the undersigned’s request for the release of
medical records.

That I am executing this affidavit to attest to the truth of the foregoing narration of facts
and for whatever other purpose this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand on this 7th day of January,
2020 at Zamboanga City, Philippines.

Affiant

SUBSCRIBED AND SWORN to before me on this __ day of January, 2020 at

Zamboanga City, Philippines. Affiant having exhibited to me her _____ Id Card bearing no.
___________________ issued at Zamboanga City.
 ATTY. JAN CEASAR A. CLIMACO
Doc. No. 240;
Page No. 49; Notary Public for Zamboanga City
Book No. 14;
Until December 31, 2020
Series of 2020.
CASTILLO & CLIMACO

Grnd Flr. Mendoza Bldg., Pilar St., Z.C.

IBP No. 059425 / Jan. 9,2019 / Z.C.

PTR No.2034879 / January 4, 2020 / Z.C.

Attorney’s Roll No. 67048

MCLE- Compliance No.VI-0014578