I, ____________________________________________________________________, of legal age,
married/single and residing at ___________________________________________, after having sworn
in accordance with law, hereby depose and state: 1. That I am the ________________ of the late
______________________________________, who was insured in the Government Service Insurance
System and died on _______________________________;
2. That I took charge in the interment of the above-mentioned deceased member and as such I was
responsible for the burial expenses incidental thereto;
3. That the following burial expenses were incurred in the interment of the deceased: Funeral service P
Cemetery lot Burial permit Coffin Music Food & Drinks (served to the people who came to condole with
the bereaved family) Church rites Tomb Miscellaneous TOTAL P
_____________________________________
Affiant CORROBORATION We, the undersigned, Filipinos, of legal age and with postal address indicated
below our signatures, after having duly sworn to in accordance with law depose and say: That having
personal knowledge of the facts of the death of the insured
Mr./Mrs./Ms._____________________________________________, who died on
______________________ at ___________________________________, do hereby declare and
confirm the truth of the statements made herein by claimant/affiant.
___________________________________ Signature of Witness
___________________________________ Signature of Witness Address:
________________________________________ Address:
_______________________________________ Subscribed and sworn to before me this _______ day of
_________________, 20___ in the city of Pasay, Philippines, affiant(s)/witness(es) exhibiting to me,
respectively, their Community Tax Certificates and the following valid government identifications: Name
CTC No. Place of Issue Date Issued NOTARY PUBLIC Doc. No. _________ Page No.__________ Book
No.__________ Series of 201______ Expiry date: December 31, _______
EPUBLIC OF THE PHILIPPINES ) CITY/MUN. OF _____________________) WAIVER OF RIGHTS TO CLAIM
We, _____________________, ____________________, __________________,
_____________________, _____________________ and _____________________, all of legal age,
Filipino citizens and residents of __________________________________, after having been duly sworn
to in accordance with law, depose and state; That we are the surviving legitimate heirs / beneficiaries of
the deceased-insured ____________________________; That for reasons of gratuity and generosity, we
hereby waive all our rights and interest to claim the insurance benefits on the life of the aforementioned
deceasedinsured, in favor of __________________________; That we execute this waiver, freely and
voluntarily to attest to the foregoing facts and statements and for whatever legal purpose it may serve.
IN WITNESS WHEREOF, we have herewith affixed our signatures this _______________ day of
_________ at ______________. Name of Affiant Signature CTC No. Issued at Issued on
_____________________ ________________ ___________ _________ _________
_____________________ ________________ ___________ _________ _________
_____________________ ________________ ___________ _________ _________
_____________________ ________________ ___________ _________ _________
_____________________ ________________ ___________ _________ _________
_____________________ ________________ ___________ _________ _________ ACKNOWLEDGMENT
Republic of the Philippines (____________________) Before me, a Notary Public of ____________,
personally appeared the following persons with their respective Community Tax Certificates, all of them
known to me and to me known to be the same persons who executed the foregoing document and they
acknowledged that the same is their free and voluntary act and deed.
_____________________________ ______________________________ Notary Public Doc. No.
_____________ Page No. _____________ Book No. _____________ Series of _____________ CLAIMS-
039-1004-2
