Republic of the Philippines...) Quezon City.........................)

AFFIDAVIT OF LIABILITY

I, ______________________________, Filipino, of legal age and with residence at ________________________________________, after having been duly sworn to in accordance with law, do hereby depose and state that:

1. My___________________, ____________________________was an active member Relationship to Deceased Name of Deceased of the Mutual Aid System (MAS) Plan _2_ of the Philippine Public School Teachers Association (PPSTA) at the time of his/her death on ______________ ; Date of Death

2. I am one of the beneficiaries of ___________________________in his/her PPSTA MAS; Name of Deceased

3. Considering the measly amount of the death benefit from PPSTA of

___________________________ and upon my request as well as prior approval of my co- Name of Deceased

beneficiaries, PPSTA entrusted to me the said death benefit in full;

4. I assume full and release PPSTA of responsibility and liability should my co-beneficiary/ies or his/her/their authorized representative/s or agent/s file a separate claim before PPSTA for the release of his/her/their share/s in death benefit from the aforesaid Association of__________________________and Name of Deceased

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 set my hand this ____th day of _________________, 2012 at Quezon City, Philippines.

______________________________ Signature Over Printed Name of Affiant-Claimant CTC No. _____________________ Issued at ____________________ Issued on ____________________ SUBSCRIBED AND SWORN to before me this ___th day of ___________________, 2012 at

Quezon City, Philippines.

NOTARY PUBLIC Doc. No. __________; Page No. __________; Book No. __________; Series of 2012

1 Name of Claimant/Beneficiary2 Present Address3 Date of Birth Age Status4 Occupation Place of Business/Employment5 Name of Deceased Member6 Cause of Death Date of death7 Name of Parents of the Deceased : Father

(Indicate if parents are already deceased) Mother8 Your relationship with the deceased:9 Name of surviving Husband/Wife of deceased:10 State number and names of children of the deceased:

*If the space provided is not enough, please continue at the back.11 State name of beneficiaries who are minors. (below 18 years old)

12 Minor children under the custody of their : FatherMother

I hereby certify that the foregoing facts are true and correct. Further, I understand that uponreceipt of the proceeds of this claim, the PPSTA shall be released and forever discharged from anyliability whatsoever arising from the membership of the deceased with PPSTA.

Beneficiary's Signature

Right ID PictureContact Number/s

E-mail address*Please ensure that your signature in this form is similar with your signature in the two (2) valid IDs that you will submit.

PHILIPPINE PUBLIC SCHOOL TEACHERS ASSOCIATION245 Banawe St., Quezon City

INFORMATION SHEET FOR BENEFICIARIES(To be accomplished by Claimant/Beneficiary of Legal Age)

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Alive DeceasedDate of Birth