REPUBLIC OF THE PHILIPPINES )

CITY OF __________________ -----------S.S)

AFFIDAVIT

I, ____________________, married, of legal age, Filipino, and with postal address at J.

_____________________, ___________________, Philippines, after having been duly sworn to
in accordance with law, do hereby deposes and states, that:

1. I am not engaged in any business or profession.

2. That, I obtain my income from doing numerous special task/ activities.

3. I am executing this Affidavit to manifest my desire to continue my status as self-

employed in my Phil Health account.

4. I am executing this Affidavit to attest to the truth of the foregoing facts and to use the
same for whatever legal purpose it may serve;
5. This affidavit is not executed to circumvent any law or to avoid any just and legal

obligations but solely for reasons above-stated.

IN WITNESS WHEREOF, I have hereunto affixed my signature this _____ day

of ________ 2021 in City of _________________.

__________________________
Affiant

SUBSCRIBED AND SWORN to before me this ________ day of ______,

2021 in City of __________________, affiant exhibiting to me her ID number ____________.

Doc. No. _______;

Page No. _______;
Book No. ______;
Series of 2021