(Affidavit of Support - for PhilHealth)

REPUBLIC OF THE PHILIPPINES)

Province of ____________________) S.S.

City/Municipality of _____________)

x-----------------------x

AFFIDAVIT OF SUPPORT

I, _____________, Filipino, (single / married / widow), of legal age, and a resident of

_____________, Philippines, having been duly sworn in accordance with law, hereby depose and state:

1. That I am presently applying for membership of 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;

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 set my hand this _____________ in the City of _____________,
Philippines.

AFFIANT

SUBSCRIBED AND SWORN to before me, this _____________, by the Affiant who is personally
known to me (or whom I have identified through competent evidence of identity) and who exhibited
his/her Community Tax Certificate No. _____________ issued at _____________ on _____________.

NOTARY PUBLIC

Doc. No. ______;

Page No. ______;
Book No.______;
Series of 20____.