Affidavit of Support (for Philhealth)

Republic of the Philippines )
City of ______               ) S.S.


            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.


            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