Republic of the Philippines )

City of Ormoc ) S.S.

AFFIDAVIT OF MEAGER INCOME

I, LUCIL P. ACUÑA, of legal age, Filipino and a resident of Brgy.

Ipil, Ormoc City Leyte, after having been duly sworn to in accordance
with law, do hereby depose and state:

1. That I am a member of Philhealth;

2. That my gross monthly income is below Five Thousand

(Ph5,000.00) Pesos as housemaid;

3. That I execute this affidavit to attest to the truth of the foregoing

statements and for whatever legal purpose it may serve.

WITNESS WHEREOF, I have hereunto affixed my signature this

_ day of ____, 2020 in Ormoc City.

LUCIL P. ACUÑA
Affiant
PhilHealth No. 13-025492883-7

SUBSCRIBED AND SWORN TO before me this _ day of ____,

2020 in Ormoc City.

Doc. No.__
Page No.__
Book No.__
Series of 2020