Republic of the Philippines )

Province of Pampanga ) S.S.

City of San Fernando )

AFFIDAVIT

I, ARLAINE N. AQUINO, Filipino, of legal age and residents of Sunrise Village, San Matias,
Sto. Tomas, Pampanga, after having been sworn on oath in accordance with law hereby depose
and state:

1. That I am a bona fide member of Philippine Health;

2. That it appears in my record at Philippine Health identification card that my signature is

not the same as my new signature which I use in all my transactions now;

3. That I have changed my signature and I do not intend to use the previous one in all my
future transactions;

4. That I hereby declare and attest that the specimen below is my new signature:

A B

New Signature Previous Signature

5. That I make this solemn declaration conscientiously believing the same to be true;

6. That I execute this affidavit to attest to the truth of the foregoing statements and whatever
legal purposes and intents this may serve.

IN WITNESS WHEREOF, I have hereunto set our hands this ___________________at the City
of San Fernando, Pampanga.

ARLAINE N. AQUINO
Affiant

SUBSCRIBED AND SWORN to before me on the date and place above-stated.

Doc. No.
Page No.
Book No.
Series of 2018