REPUBLIC OF THE PHILIPPINES)

PROVINCE OF OCCIDENTAL MINDORO)S.S

MUNICIPALITY OF SABLAYAN)

AFFIDAVIT OF EARNEST EFFORTS

I, LIZA S. DELA CRUZ Filipino, of legal age, single and presently residing
at Barangay ________, Sablayan, Occidental Mindoro, after having been duly
sworn to in accordance with law, do hereby depose and say:

1. That I am the surviving brother of ________________ who died on

_______________(date of death) in ________________(place if death) because
of head injuries sustained in a vehicular accident as per autopsy
report/medical certificate result conducted by Dr.
___________________herein attached as ANNEX “A”;

2. As evidence of my legal relation to the deceased, photocopy of my

birth certificate are herein attached “ANNEX “B” and

3. That at the time of the incident, our sister was a duly licensed
____________ (profession) carrying ____________ License No. 123456 and
was a bonafide member of Government Service Insurance System with
PIN No.__________________.

4. That at the time of our sister’s death, she has a subsisting valid
marriage with____________________, as evidence of such marriage,
attached is the copy of their marriage certificate herein attached as
ANNEX “C”

5. That years before our sister’s death, her husband abandoned her and
since then we have not heard from him:

6. That we have exerted earnest efforts to locate him and reported his
absence to the proper authorities as evidence by the Police Blotter
herein attached as ANNE “D”;

7. That despite exerting earnest efforts to locate him, his whereabouts

are still unknown to present:

8. That I am executing this affidavit in support of my application for

insurance claim with _____________, to attest to the truth of the foregoing,
and for whatever legal purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 6th day of

October 2013 at Makati City, Philippines.

LIZA S. DELA CRUZ

Affiant

SUBSCRIBED AND SWORN to before me this ___th day of June, 2018

in the Municipality of Sablayan, Occidental Mindoro, Philippines, affiant
exhibiting to me her competent evidence of identity by way of CTC/I.D. No.
__________________ issued at __________________, Philippines
on _________________.

Doc No. : _____

Page No.: ______
Book No.: ______
Series of 2018