Republic of the Philippines)

Taguig City ) S.s.

x----------------------------------------------x

AFFIDAVIT

I, NORA T. BELLEZA, Filipino, of legal age, single and a

resident of Blk. 165, Lot 11, Central Bicutan, Taguig City, after
having been duly sworn to in accordance with law hereby states:

1. That I am applying for at Makati Medical Center, Makati

City, and in connection therewith, I am required to submit a
sworn statement of my economic status, hence this affidavit;

2. That I would like to state under oath that I am unemployed

and my source of income is with an average income of per
month. I am dependent on the support of my wife who is a with
a basic salary of per month;

3. That I am a Senior Citizen, thus, not employed have no

earning/no source of income either not engaged in any business
from self-employment since May 2007. As proof attached
herewith is a copy of Certification issued by our Barangay:

4. That I am executing this affidavit to attest to the truth of

the foregoing facts for whatever legal intents and purposes this
may serve.

IN WITNESSED WHEREOF, I have hereunto affixed my

signature this 24th of May 2017 at Taguig City.

NORA T. BELLEZA
Affiant

SUBSCRIBED AND SWORN to before me this 24th day of

May 2017 at Taguig City. Affiant exhibited to me her Senior
Citizen ID with no. 22546-12 and Voter’s ID with no. 7607-
0829C-E2752NTB200000.
Republic of the Philippines)
Taguig City ) S.s.
x----------------------------------------------x

AFFIDAVIT OF ECONOMIC STATUS

I, ROBERTO R. BAUTISTA, Filipino, of legal age, married and a
resident of 22 Road 2, Purok 6B, Lower Bicutan, Taguig City, after
having been duly sworn to in accordance with law hereby states, that:

1. I am applying for Health Card at Makati Medical Center, Makati

City, and in connection therewith, I am required to submit a
sworn statement of my economic status, hence this affidavit;

2. I would like to state under oath that I am unemployed, have no

source of income and indigent. As proof a copy of my
Certificate of Indigency is hereto attached as Annex “A”;

3. I am dependent only with the support of my son Ronnirenz R.

Bautista who is a tricycle driver whose average earning is
Php2,000.00 per month;

4. That I am executing this affidavit for Makati Medical Center

requirements and to attest to the truth of the foregoing facts
and for whatever legal intents and purposes this may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature

this 26th of August 2020 at Taguig City.

ROBERTO R. BAUTISTA
Affiant

SUBSCRIBED AND SWORN to before me this 26th of August

2020 at Taguig City. Affiant exhibited to me his Driver’s License with
no. N01-96-193620 and SSS old ID with no. 33-1763179-0.

MARVIN KRIS T. MACAIRAN

Public Attorney II
Roll No. 61603
IBP Lifetime Member 013347
(Pursuant to PAO Law, R.A. 9406)