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Republic of the Philippines )

_______________
) S.S.

AFFIDAVIT OF CLAIM WITH WAIVER OF RIGHTS


We, __________________________________, all of legal age, Filipinos,
and residents of ______________________________________, after having
been duly sworn in accordance with law, depose and state under oath
that:
1.

We hereby declare that we are the only surviving heirs of the


deceased depositor, _____________________, who died on
______________, a copy of the Certificate of Death is hereto
attached as Annex A. Likewise, we further state under
pain/penalty of perjury, punishable by imprisonment
under the Revised Penal Code, that we do not know any
other heirs of the decedent; further, decedent does not
have any known debts or obligations unpaid at the time
of his/her death;

2.

At the time of his death, ___________________ left a Savings


Deposit Account/s with the ________________, ______________
Branch under Savings Account No. _______________ with a
remaining balance of Php __________________;

3.

The aforestated deposit is the only asset of the said deceased


depositor;

4.

We hereby request the __________________ Bank _______________


Branch to release the balance of the said deposit account in
favor of the undersigned as we are the only surviving heirs of
the deceased depositor;

5.

We hereby hold the __________________ Bank _______________


Branch free and harmless from any claim or suit that may be
brought against it by reason of the release of the said amount in
favor of the undersigned and we hereby undertake to indemnify
the said bank in the event that it suffers damages should any
heir or creditor subsequently claim deprivation of any rights by
virtue of this release and settlement;

6.

We are executing this Joint Affidavit to attest to the truth of the


foregoing facts and to facilitate our request for the release of
the amount of Php ___________ by the __________________ Bank
______________ Branch in our favor.
FURTHER AFFIANTS SAYETH NAUGHT.

WITNESS OUR HANDS this ___ day of __________ 2015 in


____________.

Affiant

Affiant

Affiant

Affiant
Affiant

SUBSCRIBED AND SWORN to before me this ____ day of


_____________, affiants exhibiting to me:
AFFIANT

I.D.

I.D. NO.

VALID UNTIL

NOTARY PUBLIC

Doc. No. ____;


Page No. ____;
Book No. ____;
Series of 2016.

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