REPUBLIC OF THE PHILIPPINES)

Province of ____________________) S.S.

City/Municipality of _____________)x - - - - - - - - - - - - - - - - - - - - -x

JOINT AFFIDAVIT

We, _____________ and _____________, both of legal ages, Filipinos,

and residents of _____________ and _____________, respectively, after having
been duly sworn to in accordance with law, do hereby depose and state the
following:

That we are ________(state the position or relationship or status i.e Barangay

Officials of the aforementioned Barangay) being the _____________ and
_____________,respectively.

That we know the person of _____________ because he was a resident of the

aforementioned Barangay of which we are officials;

That we know for a fact the said _____________ died on _____________ at

_____________ due to _____________;

That we are executing this affidavit to attest to the truthfulness of the fact of
death of the person of _____________ and for whatever legal purposes that this
statement may serve.

IN WITNESS WHEREOF, we have hereunto set our hands this

_____________, in the City of _____________, Philippines.

AFFIANT AFFIANT

SUBSCRIBED AND SWORN to before me, this _____________, by _________

who exhibited to me (his/her) Community Tax Certificate No. _____________
issued at _____________ on _____________ and by _____________ who
exhibited to me (his/her) Community Tax Certificate No. _____________ issued
at _____________ on _____________.

Notary Public

Doc. No. ______;

Page No. ______;

Book No. ______;

Series of ______;