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I, _________________________, of legal age, widow, Filipino and residing at _____________________________ after being duly sworn to, in accordance with law, do hereby depose and say: 1. That I am the mother of _______________________, a minor, who has an interest in the proceeds of insurance on the life of the late _______________________, my deceased husband, as well as the GSIS/SSS Fund and Pag-Ibig Fund benefits of the said deceased; 2. That I am the guardian of the above-named minor; 3. That the said minor is under my care and custody; 4. That I am competent to receive on behalf of the said minor the proceeds of insurance of the deceased, as well as the latters benefits under the GSIS/SSS Fund and Pag-Ibig Fund and any amount due her; 5. That I am not an imbecile, insane, a vagrant or a vicious person or a habitual drunkard or a habitual criminal, and have not abandoned, neglected or refused to support said minor or caused her to commit offenses against the law. Done this _____ _______________________. day of _______________________ at

Witness: _______________________

_______________________ Affiant

CORROBORATION We, _____________________________ and _____________________________, both of legal age, Filipinos and residents of _______________________________ and _________________________________, respectively, and _____________________ (relationship) and ____________________, respectively, hereby confirm the foregoing statements of _______________________, to be true and correct.

_______________________ Affiant

_______________________ Affiant

SUBCRIBED AND SWORN to before me this _____day of _______________________ at _______________________. Affiants exhibited to me their respective Identification Cards/Residence Certificates as follows:
Name of Affiant CTC/ID No. Issued at Issued on / Expiry

Doc. No. _____; Page No. _____; Book No. _____; Series of _____.