Republic of the Philippines )

City/Municipality of _____________ )

AFFIDAVIT

I, ______________________________________, of legal age, Filipino, single/married,

with business address at _________________________________________ after having been
duly sworn to in accordance with the law, hereby depose and say that:

1. That I am a Medical Doctor by profession and registered with the Bureau of Internal
Revenue RDO ______, ____________ City with Tax Identification No.
_____________________.

2. That I am currently holding clinic at _________________________, __________

City.

3. That on March 3, 2014, the Bureau of Internal Revenue released Revenue

Regulation No. 4-2014 Guidelines and Policies for the Monitoring of Service fee of
Professionals;

4. That I charge the following professional fees to my patient:

a) Consultation fee – PAmount
b) Type of service – From PAmount To PAmount
c) Type of service – From PAmount To PAmount

The above-rates would vary depending on the classification, relation of patient,

difficulty of cases, length of service, etc.

5. That the manner of billing for in-patients is through the hospital;

6. That professional fees paid by Senior Citizens/PWDs are discounted by 20%;

7. That I am executing this affidavit to attest to the veracity of the foregoing facts and
for all intents and for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ___________ day of

___________, at __________________________.

_______________________________
NAME
Affiant

SUBCRIBED AND SWORN to before me, in ____________, this __________ day of

_________________ with Community Tax Certificate No. _____________________ issued at
__________________ on _________________.

NOTARY PUBLIC

Doc No. _______

Page No. _______
Book No. _______
Series of 2014.