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AFFIDAVIT OF SUPPORT FOR PHILHEALTH

REPUBLIC OF THE PHILIPPINES )


_____________________________ ) SS.
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
say:
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 over Printed Name)
SUBSCRIBED AND SWORN TO before me, a notary public in and for
_____________________ this ____ day of ____________ 20___. The affiant, whom I identified
through the following competent evidence of identity: (ID type and number), valid from (date)
to (date) issued by (issuing authority), personally signed the foregoing instrument before me
and avowed under penalty of law to the whole truth of the contents of said instrument.
Notary Public
Doc. No. ..;
Page No. .;
Book No. .;
Series of 2010.

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