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WITNESSETH, THAT :
1. I am the child and sole surviving heir of the late Ester L. Campos who died at
UERMMC, Aurora Boulevard, Quezon City, Philippines on September 5, 2005,
respectively;
2. Said deceased died intestate, without leaving a will and whom, at the time of
her death did not leave any outstanding obligations whatsoever;
3. At the time of her death, the said deceased left certain benefits and
emoluments which are due or payable to her from the Philippine Health Insurance
Corporation (PHILHEALTH);
1._____________________(WITNESSES) 2._______________________
Page 2
ACKNOWLEDGMENT
BEFORE ME, a Notary Public, for and in Manila, Philippines, this ____
day of _________________________, 2005, personally appeared, PRINCESS
ESTER CAMPOS-BARREDO with Philippine Passport No. HH472535 issued at
Department of Foreign Affairs, Manila on July 06, 2001, known to me and to me
known to be the same person who executed the foregoing instrument and
acknowledged to me that the same is her free and voluntary act and deed.