Republic of the Philippines)

City of Mandaue) S.S.

AFFIDAVIT OF INCOME DECLARATION

I, GIRLIE MERCADER, of legal age, Filipino, single and presently residing

at Poblacion, Barili, Cebu, after being duly sworn to in accordance with law, hereby
depose and state that:

1. I am currently unemployed and I am not earning any income;

2. I am executing this Affidavit as a requirement of PhilHealth; and

3. I am executing this affidavit to confirm and affirm the foregoing facts and for
whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 31st day of

December, 2019 at Mandaue City, Cebu.

_______________
GIRLIE MERCADER
PHIC ID 11111111

SUBSCRIBED AND SWORN to before me in the City of Mandaue this 31st

day of December, 2019 by affiant, who have satisfactorily proven to me her identity
through her identifying document, that she is the same person who personally
signed before me the foregoing Affidavit of Declaration of Income and
acknowledged that she executed the same.