FPC011

PROOF OF SURVIVING LEGAL HEIRS

1. 2. 3. Name of deceased in full Residence at time of death (complete address) Name of Employer and address Position or assignment held at the time of death 4. (a) Date and place of deceaseds birth (Date) (b) From what source was date of birth obtained 5. (a) Date and place of death (Date) (b) Cause of death 6. 7. In what capacity, or by what title, do you claim this benefit? State whether the deceased has a will and testament passed upon by a court and a regular administrator of the deceaseds estate appointed by the court. Give names and addresses of Surviving Heirs of deceased as of the date of his/her death in the following order; (If any of them are under age or legally incompetent state also the names of their guardian, if they are under guardianship) (a) Widow/Widower (b) Children (Include all children whether they are legitimate, legally adopted, acknowledged natural or illegitimate. Attach their birth or Baptismal Certificates or adoption papers). State whether legitimate, legally adopted, acknowledged natural or illegitimate (Place) (Place)

8.

Name of Children 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. (c) Name of Parents

Date of Birth

State whether still living or already deceased

Date of Birth

(d) Paternal and maternal grandparents in the absence of persons called for in items (b), and (c) above.

(e) Brothers and sisters in the absence of persons called for in items (b), (c) and (d) above. (Use another sheet if necessary) Name of Brother/Sister 1. 2. 3. Age Address Guardian of Minors

(f) Children of deceased brother/s and sister/s. (State age, address and guardian of minors) This is required only in the absence of items (b), c) and (d).

(g) Other relatives. (State relationship to deceased)

The undersigned hereby make claim to the Pag-IBIG provident benefits and agree that the written statements and affidavits and all other papers called for the instructions hereon shall constitute and they are hereby made a part of these Proofs of Surviving Legal Heirs and further agree that the furnishings of the form or any other forms supplemented thereto, to said Pag-IBIG Fund shall constitute nor be considered an admission by it that the deceased was entitled to the retirement provident benefits under PD 1530 as amended by PD 1752, as amended by Executive Order No. 90, further amended by RA 7742; nor a waiver of any of its right or defenses.

____________________________ CLAIMANT CTC No. _____________________ Place/Date Issued _____________

______________________________ CLAIMANT CTC No. _______________________ Place/Date Issued ________________

___________________________ CLAIMANT CTC No. ____________________ Place/Date Issued ____________

With my marital consent:

____________________________ SPOUSE

_____________________________ SPOUSE

___________________________ SPOUSE

SIGNED IN THE PRESENCE OF:

__________________________________________

____________________________________________

ACKNOWLEDGMENT

REPUBLIC OF THE PHILIPPINES )S.S. PROVINCE/CITY OF ______________ )

BEFORE ME, a Notary Public for and in the______________________________________ this __________ day of _________________________________, 20_________, personally appeared the above-named persons with their identifying documents written below their names and signatures , personally known to me and to me known and identified by me through competent evidence presenting this integrally complete instrument. Representing to me that the signatures in the instrument were voluntarily affixed by them for the purposes declaring that they have executed the instrument as their free and voluntary act and deed. Further, persons acting in representative capacity declare that they have been given authority to sign in said capacity. The foregoing instrument relates to a Proofs of Surviving Legal Heirs consisting of ________ (___) pages including this page of Acknowledgment, signed by the parties and their instrumental witnesses on all pages thereof, in my presence, and sealed with my Notarial Seal. WITNESS MY HAND AND NOTARIAL SEAL. NOTARY PUBLIC Doc. No. _________; Page No. _________; Book No._________; Series of _________.