SWORN AFFIDAVIT

We, Cherry M. Corpuz and Arnel L. Mindaros, both of legal age, Filipino citizens and
residents of Brgy. Quezon, San Isidro, Isabela after having been duly sworn in
accordance with law, hereby depose and say that:

1. We willingly and knowingly executed the attached Promissory Note in favor

of De Vera Medical Center, Inc. for the indebtedness of Romeo Sarangay Jr. (the
“Patient”) consisting of all hospital fees from date of admission to the date of
discharge amounting to Twenty thousand one hundred twenty-nine and
5/100 (P20,129.05);

2. Arnel L. Mindaros offers as a security to the said indebtedness a motor vehicle

registered under his name bearing LTO Plate No. BD51867;

3. We further understand that in the event that the amount of outstanding

hospital bill will not be paid on or before June 30, 2019, said security shall be
subject to foreclosure in the manner and form prescribed by law;

4. We are executing this Affidavit to attest to the correctness and truthfulness of

the foregoing.

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

______________ 2019 in Santiago City.

Cherry M. Corpuz Arnel L. Mindaros

Affiant Affiant

SUBSCRIBED AND SWORN to before me this ______ day of _______________ 2019

in Santiago City.

Doc. No. _____;

Page No. ____;
Book No. ____;
Series of 2019.