Republic of the Philippines )

Province of Bulacan ) S.S.

x - - - - - - - - - - - - - - - - - - - - x

AFFIDAVIT

I, ANASTACIA DE MESA DELA CRUZ, of legal age, widow, Filipino and a
resident of Barangay Casalat, San Ildefonso, Philippines, having been duly
sworn in accordance with law, hereby depose and state:

1. That, I married EDUARDO DELA CRUZ on March 19, 1999;

2. That, my husband EDUARDO DELA CRUZ died on November 19,
2013 in Barangay Casalat, San Ildefonso, Philippines;

3. That, the late EDUARDO DELA CRUZ was hired on September 4,
1979 by Philippine Development & Industrial Corporation and was
issued a Social Security System (SSS) number 03-5549731-3;

4. That, as per record obtained from the SSS, it is had inadvertently and
erroneously written that:
a. the father of the late EDUARDO DELA CRUZ is EDGARDO and his
mother is ANASTACIA,
b. the name of beneficiaries enumerated is EDUARDO DELA CRUZ as
father and BIRHINIA DEL ROSARIO as mother,
c. the name of dependents enumerated is PATRISIO as father and
BIRHINIA as mother,

5. That, EDUARDO DELA CRUZ was born on November 22, 1941 with
PATRICIO DELA CRUZ as his father and VIRGINIA DEL ROSARIO as
his mother;

That I am executing this Affidavit to attest to the truth of the foregoing
facts and to explain the discrepancy in the Social Security System membership
form of the late EDUARDO DEL ROSARIO DELA CRUZ as regards to the name
of his mother, father, and wife as beneficiaries and dependents;

Further, I am declaring that the father of the late EDUARDO DELA CRUZ
is PATRICIO DELA CRUZ, his mother is VIRGINIA DEL ROSARIO DELA
CRUZ and his wife is the undersigned affiant.

IN WITNESS WHEREOF, I have hereunto set my hand this 21
st
of July
2014, at Bulacan, Philippines.

ANASTACIA DE MESA DELA CRUZ
Affiant
SUBSCRIBED AND SWORN to before me this 21
st
day of July, 2014, here
in Bulacan, Philippines.


REVELYN C. CAYETANO-ABDUHALIM
Notary Public, until December 31, 2015
Roll of Attorneys No. 63815
IBP Bulacan Lifetime Member No. 012703
PTR No. 2073510/June 5, 2014
San Ildefonso, Bulacan

Doc. No. : _____
Page No. : _____
Book No. : _____
Series of 2014.