REPUBLIC OF THE PHILIPPINES)

CITY OF CAGAYAN DE ORO ) S.S.

AFFIDAVIT OF NO INCOME

I, ______________________, of legal age, single, Filipino and a resident

of ________________________, Philippines, after being sworn to in accordance
with law hereby depose and say that:

I am a bonafide member of the Philippine Health Insurance Corp.

(Philhealth) with assigned I. D. No. ______________;

I am a full-time student of _____________. I am fully dependent on my

parents for financial support as I am not gainfully employed. Through them, I
intend to give voluntary contribution for my membership with Philhealth;

I am executing this affidavit to attest to the truth of the foregoing statement

and for whatever purpose this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 22 nd day of

January 2020 in Cagayan de Oro City.