Free affidavit of death 36
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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: That I am
the __________ of the late ____________________ , who died at
____________________________ on _____________________________________.
That the names and pertinent data of the aforementioned deceased member’s immediate relatives
and next to kin are as follows:
LEGITIMATE HUSBAND/WIFE
DATE & PLACE OF MARRIAGE
ADDRESS

(if dead, give date and place of
death instead)

COMMON-LAW HUSBAND/WIFE

LEGITIMATE/ LEGITIMATED/

LEGALLY ADOPTED CHILDREN

ILLEGITIMATE CHILDREN

MOTHER/FATHER

DATE OF UNION

ADDRESS

(if dead, give date and place of
death instead)
(if minor, give name, address and

DATE/ PLACE OF BIRTH

relationship of guardia