REPUBLIC OF THE PHILIPPINES )

____________________________ ) S.S

AFFIDAVIT OF PROOF OF INCOME

I, ________________________, of legal age, Filipino citizen,

married, and a resident of ___________________________,
Philippines, after having been duly sworn to in accordance with law, do
hereby depose and state THAT:

1. I am a member of the Philippine Health Insurance Corporation

(PhilHealth) with PIN: _______________________;

2. To this date, I am not employed in any capacity at any

corporation, company, individual person or with the government;

3. I am a housewife and my husband, ________________, is the

only one working for our family as an ________________;

4. I am executing this Affidavit to attest to the truth of the foregoing

statements and for whatever legal intents and purposes this
may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature

this ___ day of _____________, 2020, at ______________, Philippines.

___________________
Affiant

SUBSCRIBED AND SWORN to before me on the date and place

indicated above. Affiant exhibited before me his/her
________________________ issued by the ____________________,
valid until__________________.