Republic of the Philippines)
Province of ____________________)S.S.
City/Municipality of _____________)
x – – – – – – – – – – x
AFFIDAVIT OF SUPPORT
I, _____________, Filipino, (single / married / widow), of legal age, and a resident of _____________, Philippines, having been duly sworn in accordance with law, hereby depose and state:
That I am presently applying for membership of Philhealth;
That I am declaring my (father/mother), _____________, ______ years old as one of my legal dependents who is dependent upon me for regular support;
That I am executing this Affidavit for the purpose of receiving benefits from PhilHealth for the aforementioned dependent;
That I am fully aware that any false statement or misrepresentation as to the facts mentioned above will be a ground for automatic disapproval of the PHILHEALTH application.
IN WITNESS WHEREOF, I have set my hand this _____________ in the City of _____________, Philippines.