REPUBLIC OF THE PHILIPPINES)

Province of____________________) S.S.

City/Municipality of_____________)
x---------------------------------------x

AFFIDAVIT OF SUPPORT FOR PHILHEALTH (Parent as

Dependent)

I, ________________(name of affiant)____________, Filipino, of

legal age, [single]/[married to _________(name of
spouse)_________], and a resident of
___________________(address of affiant)_______________, after
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 hereunto affixed my signature this

____day of ____________ 20___ at ____________, Philippines.

______________(Signature of Affiant)______________
(Printed Name)

SUBSCRIBED AND SWORN TO BEFORE ME, a notary public in and for

_________(City/Province)____________ this ____th day of ____________
20___. Affiant personally came and appeared with _____________(Competent
Evidence of Identity)______ issued by the _________(Government
Agency)______ on ___(date)__ at ________(place)_________, bearing his
photograph and signature, known to me as the same person who personally
signed the foregoing instrument before me and avowed under penalty of law to
the whole truth of the contents of said instrument.
 Atty _______________________________________
Notary Public
Doc. No. ____ Commission Serial No. __________________
Page No. ____ Notary Public for _______(Province/City)_____
Book No. ____ Until December 31, 20__
Series of 20__ Office: ______________(address)__________
Roll No. __________
IBP Lifetime Roll No. ________; __/__/__ ; (Province)
PTR No. _________ ; __/__/__ ; _(Province)_
MCLE Compliance Cert. No. __________; __/__/__

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