Republic of the Philippines )

City of _________ ) S.S

AFFIDAVIT OF UNDERTAKING

I/), all of legal age, married/single, Filipino, with residence at 317 San Pascual, Talavera, Nueva
Ecija, (hereinafter referred as NOK) after having been sworn in accordance with law, hereby
depose and state that:

1. OFW (LUISITO V. DE JESUS)(“Deceased”), with Philippine Passport No. XX3546151 issued

on April 23, 2009, died in King Fahad Hospital Al Baha, Kingdom of Saudi Arabia on
December 5, 2012. Employee died without leaving any last will and testament, has no
debts, and has no other surviving legal heirs except of the following:

Name of Legal Heir Relationship of the Employee

(Indicate if Minor or Legal Age)

MARK ALVIN S. DE JESUS ELDEST SON

JEFFERSON S. DE JESUS YOUNGEST SON

2. The employer of the Employee requested the Philippine Embassy in (location of

embassy, Riyadh) to transfer to the NOK the amount SAUDI RIYALS(SAR) 150,000.00 as
blood money, with authority given to the Department of Foreign Affairs to identify NOK
on the basis of appropriate Philippine government documents.

3. The NOK requests and authorizes the Office of the Undersecretary for Migrant Workers
Affairs (OUMWA) to release the Philippine peso equivalent of the blood money minus
bank and other remittance charges as follows:

a. [ ]For claiming in person by NOK

b. [ ]Bank-to-bank transfer to (_005870076715,___587 NUEVA ECIJA TALAVERA___)
under the name of (______FELICISIMA S. DE JESUS_______).
4. The NOK shall immediately distribute to all beneficiaries of the Employee whose filiation
is supported by Philippine government documents. If another beneficiary who was not
 earlier identified and did not receive a share in the blood money, the NOK shall return to
OUMWA the amount meant for the new beneficiary within 10 days from notice.

5. The NOK affirms that they have no claim against the Department of Foreign Affairs or
any of its officers or employees. In the event that another beneficiary surfaces, the NOK
shall keep free from harm and claim the Department of Foreign Affairs and defend the
latter against any proceedings that the new beneficiary may institute.

6. This Affidavit of Undertaking is executed to attest to the truth of the foregoing and
binds the NOK with the undertakings aforementioned. The NOK shall be liable for
perjury, estafa, and other related felonies or crimes for any falsehood in this Affidavit or
for non-performance of the undertakings stated therein which we assume with full
understanding of its consequences.

(Name of Affiant 1) (Name of Affiant 2)

(Government Issued ID) (Government Issued ID)

(Name of Affiant 3) (Name of Affiant 4)

(Government Issued ID) (Government Issued ID)

SUBSCRIBED AND SWORN to before me this ____ day of ____________, affiants

exhibiting to me either identification documents indicated below their respective names.

(Subscribing Officer)

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