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CONTAWE, of legal age and a resident of # 226 Sumil Street, Poblacion 2, Basud, Camarines Norte, after having been sworn to in accordance with law hereby depose and state that: I am a member of Caritas Health Shield Inc., a health maintenance organization in Quezon City. That I was issued an Insurance Certificate of Caritas Health Shield Inc., with policy No. E101 1029330. That I misplaced or lost the said insurance certificate: I exerted diligent effort to look for the lost insurance certificate but my efforts prove futile as I could not find it; Should I ever find/recover the lost insurance certificate, I undertake to voluntarily surrender the same to Caritas Health Shield Inc., NOW, THEREFORE, in consideration of the above premises, I, hereby agree to indemnify and save harmless CARITAS HEALTH SHIELD INC., from any and all actions, claims and demands growing out of any interest on said insurance certificate or any assignment thereof. AFFIANT FURTHER SAYETH NAUGHT; IN WITNESS WHEREOF, I have hereunto signed this document on _____ day of __________, 2011 in _______________, Camarines Norte.

IRENE C. CONTAWE AFFIANT SIGNED IN THE PRESENCE OF: ____________________ ____________________

REPUBLIC OF THE PHILIPPINES ) PROVINCE OF CAMARINES NORTE) S.S. MUNICIPALITY OF _______________) BEFORE ME, a Notary Public for and in the Province of Camarines Norte, Philippines, personally appeared the above-named AFFIANT with Residence Certificate No. 08231887 issued at Basud, Camarines Norte on February 1, 2011, known to me to be the same person who executed the foregoing and acknowledged to me that the same is her free and voluntary act and deed. WITNESS MY HAND AND SEAL. This _____ day of __________, 2011 at __________, Camarines Norte, Philippines.

NOTARY PUBLIC Until ____________________ PTR No. _________________ Issued on ________________ At ______________________ Doc No. ____________________ Page No. ___________________ Book No. ___________________ Series of 2011