Republic of the Philippines)

City of Calapan ) S.S.

Province of Oriental Mindoro)

AFFIDAVIT

I, ____________________________, 51 years old, Filipino, single and

a resident of __________________________, Oriental Mindoro, after having been
duly sworn in accordance with Law hereby depose and say:

1. That I am the brother of _____________________________, a plan

holder of SSS Insurance Plan;

2. That my brother died on ____________________ in

_____________________, Oriental Mindoro;

3. That I have allowed and consented to the transfer of this insurance plan to my
brother __________________________;

4. That I have waived my rights, interest and participation for any benefits in
SSS in favor of ________________________ and I no longer intend to
make SSS liable under the contract;

5. That I am executing this affidavit to attest to the truth of the foregoing as the
benefits under the said Insurance Plan was never availed during the wake of
my brother, _______________________________;

6. That I avow under penalty of law to the whole truth of the contents of this
affidavit.

IN WITNESS WHEREOF, I HAVE HEREUNTO SET MY HAND, this 9th

day of October, 2017 at Calapan City.

(Affiant)
LTO Driver’s License No. _____________

SUBSCRIBED AND SWORN TO BEFORE ME, this 9th day of October, 2017

at Calapan City.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2017.