REPUBLIC OF THE PHILIPPINES )

PROVINCE OF LAGUNA )S.S.

MUNICIPALITY OF STA. CRUZ )

SWORN AFFIDAVIT

I, FELIX D. DE LA CRUZ JR., Filipino, of legal age, and resident of Barangay

Longos, Kalayaan, Laguna, after having been sworn to in accordance with the law do
hereby depose and state:

1. That I am the common-law spouse of AMY FRANCISCO NAZ having

cohabiting with her for three (3) years;

2. That my common-law-spouse AMY FRANCISCO NAZ died on

February 1, 2019 at Santa Cruz, Laguna;

3. That my common-law spouse AMY FRANCISCO NAZ had a Blue

Card/Health Card with No. 00000275508 and I will be the one processing her
benefits considering I am his common-law spouse;

4. That my common-law spouse has never been married and remained

single as evidenced by her Certificate of No Marriage (CENOMAR) attached
as Annex A;

5. That I am exhibiting this Affidavit to attest to the truthfulness of

foregoing facts under penalty of law;

6. That I am executing this Affidavit for whatever legal purpose it may

serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 15 th day of

February 2019 at Santa Cruz, Laguna.

FELIX D. DE LA CRUZ JR
Affiant

SUBSCRIBED AND SWORN to before me this 15th day of February 2019 at

Santa Cruz, Laguna, affiant exhibiting his Driver’s license with N02-08-014953 as proof
of his identity.
Doc. No. ____
Page No. ____
Book No. ___
Series of 2019.