Republic of the Philippines )
City of ______ )
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 _______ 2014 at ______________, Philippines.
________________
Affiant
SUBSCRIBED AND SWORN to before me this ____ day of ______ 2014 in _________, Philippines, affiant exhibiting to me his/her competent evidence of identity by way of _______________ issued at ___________ on ________________.
Doc No. : _____
Page No.: ______
Book No.: ______
Series of 2014 Notary Public