Republic of the Philippines

Province of Aklan
Municipality of Kalibo

)
) S.S.
)

AFFIDAVIT OF LIABILITY
I, TEODORO B. JACINTO, Filipino, of legal age and a resident of No.
0579, Osmea Ave., Brgy. Estancia, Kalibo, Aklan, after having been duly
sworn to in accordance with law, do hereby depose and state that:
1.

My mother, REMEDIOS B. JACINTO was an active member of the

Mutual Aid System (MAS) Plan 1 of the Philippine Public School
Teachers Association (PPSTA) at the time of her death on October
18, 2014;

2.

I am the only surviving beneficiary of REMEDIOS B. JACINTO in

her PPSTA MAS;

3.

The two other beneficiaries were my siblings who both predeceased our mother REMEDIOS B. JACINTO. The heirs of said
beneficiaries are all currently residing abroad and have
established means for living;

4.

Securing a Deed of Waiver from the aforementioned heirs would

be too onerous due to the distance of their residences, in relation
to the trifling amount of the death claim;

5.

Considering the measly amount of the death benefit from PPSTA

of REMEDIOS B. JACINTO and upon my request as well as prior
approval of the heirs of my co- beneficiaries, PPSTA entrusted to
me the said death benefit in full;

4.

I assume full, and release PPSTA, of responsibility and liability

should the heirs of my co-beneficiaries or their authorized
representative/s or agent/s file a separate claim before PPSTA for
the release their shares in the death benefit from the aforesaid
Association of REMEDIOS B. JACINTO; and

5.

I am executing this affidavit to attest to the veracity of the facts

above-stated and for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto

________________________, at Kalibo, Aklan, Philippines.

set my hand this

TEODORO B. JACINTO
Affiant
ID No. _______________________
SUBSCRIBED AND SWORN to before me this ________________, at
Kalibo, Aklan, Philippines.