Republic of the Philippines

Camiling, Tarlac

)
) S.S.

AFFIDAVIT
I, GERALD J. DIN, 48 years old, widower, Filipino citizen, and
resident of Barangay Sinulatan 1st, Camiling, Tarlac, after having been
duly sworn to in accordance with law, do hereby depose and state THAT:
1. I am the husband of the late ANACLETA ABALOS DIN
(Anacleta, for brevity), who during her lifetime worked as an
Overseas Filipino Worker (OFW) registered with the Overseas
Workers Welfare Administration (OWWA);
2. Anacleta worked as a Domestic Helper in Hongkong. Sometime in
November 2014, Anacleta came home to the Philippines for a 2week vacation, and on December 8, 2014, she went back to
Hongkong;
3. On June 14, 2015, while she was in Hongkong, Anacleta passed
away due to Cardio Respiratory Arrest. When the remains of
Anacleta were shipped from Hongkong to the Philippines on June
27, 2015, the following documents were handed to us by a
certain Nelson Soriano Macasieb, to wit:
a. Original Consular Mortuary Certificate from Fatima G.
Quintin, Vice Consul of the Republic of the Philippines,
b. Original Form 11 Certificate of the Fact of Death, and
c. Machine copy of the Philippine Passport of Anacleta;
4. All the travel documents of my wife, including her passport, are
still in the possession of her employer in HongKong and there is
no certainty if her employer will send the same to me;
5. Lately, when I went to the OWWA Office in City of San Fernando,
Pampanga to apply/ file for the death benefit of my late wife, I
was required by the said agency to submit documents, one of
which is the original Philippine Passport of Anacleta;
6. I am executing this Affidavit to inform the OWWA Office, San
Fernando City, Pampanga, that I cannot submit the original
passport of Anacleta because the same is still in HongKong and I
have no idea if the said passport will ever be sent to me, and to
request the OWWA to process my claim despite the absence of
such original passport;

7. Finally, I am executing this Affidavit to attest to the truth of the

foregoing statements and for all legal intents and purposes it
may serve.
IN WITNESS WHEREOF, I have hereunto set my hand this 12 th
day of August, 2015 at Camiling, Tarlac, Philippines.
GERALD J. DIN
Affiant
SUBSCRIBED AND SWORN to before me on the date and place
indicated above. Affiant exhibited to me his Pantawid Pamilyang Pilipino
Program ID with No. 036903061-4570-00017 issued by the Department
of Social Welfare and Development, Philippines.