Republic of the Philippines )

City of ______ ) S.S.

x--------------------------x

AFFIDAVIT OF SUPPORT

I, _________________, of legal age, single/married/widow, Filipino citizen, and presently residing at _____________________, after having been duly sworn to in accordance with law, do hereby depose and say:

1. That I am presently applying for membership with Philippine Health Insurance Corporation (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; and

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 set my hand this ____ day of ___________ 20____ in ____________, _____________, Philippines.

___________________________________

Affiant

SUBSCRIBED AND SWORN TO before me this _____ day of _________ at ________________ affiant exhibited to his/her competent evidence of identity by way of _________________ issued on __________________ in _______________, Philippines.

Notary Public

Doc. No. ______;

Page No. ______;

Book No. ______;

Series of ______;