Affidavit of Loss
Affidavit of Loss
Affidavit of Loss
1. That I am the mother of Juan Paolo A. Obligacion, a minor, who is the beneficiary of
the proceeds of the PSSLAI Passbook and AFPSLAI Passbook of the late Pelito B.
Obligacion, my deceased common law spouse, as well as the GSIS/SSS Fund and
Pag-Ibig Fund benefits of the said deceased;
2. That as evidence, I attached herewith a photocopy of the Birth Certificate of Juan
Paolo Obligacion and an Affidavit Of Paternity marked as Annex “A” and Annex “B.”
3. That I am the guardian of the above-named minor;
4. That the said minor is under my care and custody;
5. That I am competent to receive on behalf of the said minor the proceeds of PSSLAI
Passbook and AFPSLAI Passbook of the deceased, as well as the latter’s benefits
under the GSIS/SSS Fund and Pag-Ibig Fund and any amount due him;
6. That I am not an imbecile, insane, a vagrant or a vicious person or a habitual drunkard
or a habitual criminal, and have not abandoned, neglected or refused to support said
minor or caused her to commit offenses against the law.
7. That I execute this affidavit to attest the truth of the foregoing statements.
Juan Paolo A. Obligacion School ID No.: 1819-0078 Naga City, Camarines Sur