REPUBLIC OF THE PHILIPPINES)Province of____________________) S.S.City/Municipality of_____________)x---------------------------------------x

AFFIDAVIT OF SUPPORT FOR PHILHEALTH (Parent as Dependent)

I, ________________(name of affiant)____________, Filipino, of legal age, [single]/[married to _________(name of spouse)_________], and a resident of ___________________(address of affiant)_______________, after having been duly sworn in accordance with law, hereby depose and state:

1. That I am presently applying for membership of Philhealth;

2. That I am declaring my __________(father/mother)________, ____, years old as one of my legal dependents who is dependent upon me for regular support;

3. That I am executing this affidavit for the purpose of receiving benefits from PhilHealth for the aforementioned dependent;

4. 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 hereunto affixed my signature this ____day of ____________ 20___ at ____________, Philippines.

______________(Signature of Affiant)______________ (Printed Name)

SUBSCRIBED AND SWORN TO BEFORE ME, a notary public in and for _________(City/Province)____________ this ____th day of ____________ 20___. Affiant personally came and appeared with _____________(Competent Evidence of Identity)______ issued by the _________(Government Agency)______ on ___(date)__ at ________(place)_________, bearing his photograph and signature, known to me as the same person who personally signed the foregoing instrument before me and avowed under penalty of law to the whole truth of the contents of said instrument.

Atty ___________________________________________Notary Public

Doc. No. ____ Commission Serial No. ____________________________ Page No. ____ Notary Public for _______(Province/City)______________Book No. ____ Until December 31, 20__Series of 20__ Office: ______________(address)____________________

Roll No. __________IBP Lifetime Roll No. _________; __/__/__ ; _(Province)_PTR No. _________ ; __/__/__ ; _(Province)_

MCLE Compliance Cert. No. __________; __/__/__