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Affidavit of Support: IN WITNESS WHEREOF, I Have Hereunto Affixed My Signature This - Day of

This affidavit declares that the affiant financially supports their father as a dependent for Medicare benefits. It states the affiant's name, employment, and Social Security number. It also provides the father's name, date and place of birth, and confirms he has no other source of income. The affiant understands any false statements could lead to denial of benefits and legal prosecution.

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CL Delabahan
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607 views1 page

Affidavit of Support: IN WITNESS WHEREOF, I Have Hereunto Affixed My Signature This - Day of

This affidavit declares that the affiant financially supports their father as a dependent for Medicare benefits. It states the affiant's name, employment, and Social Security number. It also provides the father's name, date and place of birth, and confirms he has no other source of income. The affiant understands any false statements could lead to denial of benefits and legal prosecution.

Uploaded by

CL Delabahan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Republic of the Philippines )

Province of ______________) S.S.


City of _____________ )
X - - - - - - - - - - - - - - - - - - - -/

AFFIDAVIT OF SUPPORT

THAT I, ___________, of legal age, Filipino, married and a resident of


____________, after having been duly sworn to in accordance with law, hereby depose
and say:

1. That I am presently employed at ______________ with SSS No. _________


paying Medicare contributions under RA No. 6211, otherwise known as the
Philippine Medicare Act of 1969, as amended by PD 1519;

2. That I am declaring my father __________, who was born on _________ at


____________ and he is now ____ years old, as one of my legal
dependents under the above-stated Act;

3. That my said father who has no other source of income whatsoever, is


actually depending on me for any regular support;

4. That I am executing this affidavit for the purpose of securing benefits under
the above-mentioned Act for the above-named dependent;

5. That I am aware that any false statement or misrepresentation as to facts


mentioned above will be ground for automatic disapproval of the Medicare
claim for the above-named dependent including all future claims for my self
and in behalf of all my legal dependents and prosecution under the law.

That affiant further sayeth naught.

IN WITNESS WHEREOF, I have hereunto affixed my signature this _____ day of


______ at __________

_________________
Affiant

SUBSCRIBED AND SWORN TO before me this ____ day of ______ at ____.

(Name of Lawyer)
Attorney
_______ Law Firm

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