Republic of the Philippines)

City of Calapan ) S.S.

Province of Oriental Mindoro)

AFFIDAVIT

I, EDGARDO I. VILLANUEVA, 51 years old, Filipino, single and a resident of

Brgy. Pinagsabangan I, Naujan, Oriental Mindoro, after having been duly sworn in
accordance with Law hereby depose and say:

1. That I am the brother of NESTOR I. VILLANUEVA, a plan holder of SSS

Insurance Plan;

2. That my brother died on October 12, 2016 in Pinagsabangan I, Naujan,

Oriental Mindoro;

3. That I have allowed and consented to the transfer of this insurance plan to my
brother NESTOR I. VILLANUEVA;

4. That I have waived my rights, interest and participation for any benefits in
SSS in favor of NESTOR I. VILLANUEVA and I no longer intend to make SSS
liable under the contract;

5. That I am executing this affidavit to attest to the truth of the foregoing as the
benefits under the said Insurance Plan was never availed during the wake of
my brother, NESTOR I. VILLANUEVA;

6. That I avow under penalty of law to the whole truth of the contents of this
affidavit.

IN WITNESS WHEREOF, I HAVE HEREUNTO SET MY HAND, this 9th

day of October, 2017 at Calapan City.

EDGARDO I. VILLANUEVA
(Affiant)
LTO Driver’s License No. X01-09-002515

SUBSCRIBED AND SWORN TO BEFORE ME, this 9th day of October, 2017

at Calapan City.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2017.