ANNEX A

Republic of the Philippines

City/Municipality of Victoria, Laguna S.S

SWORN STATEMENT OF RETAILERS OF DRUGS PRESCRIBED FOR CANCER, MENTAL ILLNESS,

TUBERCULOSIS AND KIDNEY DISEASE

I, _______________, of legal age, Filipino, with business address at __________________, Laguna , owner and proprietor of Drugstore and General Merchandise, after having been sworn to in accordance
with the law, certify truthfullness of the following:

Prices prior to January 1, 2021 Prices beginning to January 1, 2021

Generic name Strength/Form Brand name/Manufacturer Actual Retail Price Actual Retail Price
RIF+INH+PZA+ETHAM HCL 150MG+75MG+400MG+275MG TAB MYRIN P FORTE / PFIZER 18.5 16.5
RIF+INH+PZA+ETHAM HCL 150MG+75MG+400MG+275MG TAB FIXCOM4/ NATRAPHARM 16.8 15
RIF+INH+ETHAM HCL 150MG+75MG+275MG TAB FIXCOM3 / NATRAPHARM 14.4 12
ETHAMBUTOL HCL 400MG TABLET HAMBUTOL DMLI 5 4.5
ISONIAZID 300MG TABLET DRUGMAKERS 4 3.5
RIFAMPICIN 450MG CAPSULE EUFROPIN / LUMAR 8 7

KETOANALOGUES+ ESSENTIAL AMINO ACID 600MG TABLET KETOROSE / PHAROSE REMEDIES LTD. 25 22
RIF+INH+PZA+ETHAM HCL 150MG+75MG+400MG+275MG TAB QUADTAB / UNILAB 12.5 11.75

IN WITNESS WHEREOF, I have hereunto set my hands this 29th day of July, 2021, at

_____________________________________
Sole Proprietor/Authorized Representative

SUBSCRIBED AND SWORN to before me, this _____ day of ______________, 2021, at ______________ affiant known to me.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2021.