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CLD 1.3 A Affidavit for Death Claim Benefits
Death Claim Affidavit for SSS death benefits
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: REPUBLIC OF THE PHILIPPINES )
City / Municipality of ___________ ) S.S.
_______________________________ )
Province of ____________________)
SSS FORM CLD - 1.3 A
AFFIDAVIT FOR DEATH BENEFIT CLAIM
I, ________________, of legal age, single/married and presently residing at
_______________________________ having been sworn according to law, depose and say:
T h a t I a m t h e _ _ _ _ _ _ _ _ _ _ o f t h e l at e _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ , w h o d i e d at
____________________________ on _____________________________________.
That the names and pertinent data of the aforementioned deceased members
immediate relatives and next to kin are as follows:
ADDRESS
LEGITIMATE HUSBAND/WIFE
DATE & PLACE OF MARRIAGE
(if dead, give date and place of
death instead)
COMMON-LAW HUSBAND/WIFE
ADDRESS
DATE OF UNION
LEGITIMATE/ LEGITIMATED/
LEGALLY ADOPTED CHILDREN
DATE/ PLACE OF BIRTH
ILLEGITIMATE CHILDREN
(if dead, give date and place of
death instead)
DATE/ PLACE OF BIRTH
MOTHER/FATHER
(if minor, give name, address and
relationship of guardian)
ADDRESS
ADDRESS
(if dead, give date and place of death instead)
LEGALLY MARRIED?
NO
YES
Th at a f f i a n t f u r t h e r c e r t i f y t h at t h e d o c u m e n t s e s t abl i s h i n g t h e fa c t / s o f
__________________ such as the ______________________ could not be submitted for the
following reasons: __________________________________________________________________
FURTHER, AFFIANT SAYETH NAUGHT.
AFFIANT
SUBSCRIBED AND SWORN TO before me this _____ day of __________, 20 __ affiant
having exhibited to me his/her Res. Cert. No. A- _____________ issued at ________________
__________________ on _____________, 20 __.
NOTARY PUBLIC
Until_______________________
DOC NO.: ______________________
PAGE NO.: -------------------------------
