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Republic of the Philippines )

Province of ______________) S.S.


City of _____________ )
X - - - - - - - - - - - - - - - - - - - -/

AFFIDAVIT OF SUPPORT

THAT I, ___________, of legal age, Filipino, married and a resident of


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

1. That I am presently employed at ______________ with SSS No. _________


paying Medicare contributions under RA No. 6211, otherwise known as the
Philippine Medicare Act of 1969, as amended by PD 1519;

2. That I am declaring my father __________, who was born on _________ at


____________ and he is now ____ years old, as one of my legal
dependents under the above-stated Act;

3. That my said father who has no other source of income whatsoever, is


actually depending on me for any regular support;

4. That I am executing this affidavit for the purpose of securing benefits under
the above-mentioned Act for the above-named dependent;

5. That I am aware that any false statement or misrepresentation as to facts


mentioned above will be ground for automatic disapproval of the Medicare
claim for the above-named dependent including all future claims for my self
and in behalf of all my legal dependents and prosecution under the law.

That affiant further sayeth naught.

IN WITNESS WHEREOF, I have hereunto affixed my signature this _____ day of


______ at __________

_________________
Affiant

SUBSCRIBED AND SWORN TO before me this ____ day of ______ at ____.

(Name of Lawyer)
Attorney
_______ Law Firm

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