REPUBLIC OF THE PHILIPPINES )

ZAMBOANGA CITY ) S.S.

AFFIDAVIT OF ONE AND THE SAME PERSON

I, OMAR BAS HASS, Filipino, of legal age, married, with residence at Tandubas, Tawi-tawi,
Philippines, after being duly sworn to in accordance with law, hereby depose and state:

1. That I was born Omar Tik Hass on 03 August 1968 in Kepeng, Tandubas, Tawi-tawi (please
see attached Certificate of Live Birth);

2. That I later on got married to Rubilyn Sarama Amboy on 29 August 1995 in Kepeng,
Tandubas, Tawi-tawi, wherein my previous middle name of TIK was changed to BAS,
thereby converting my registered name to OMAR BAS HAS (please see attached Certificate of
Marriage);

3. That, much later on in life I registered with the PhilHealth system, and my name was
erroneously registered therein as OMAR AMBOY, with a likewise erroneous date of birth
registered with the PhilHealth system as 18 November 1970;

4. That I have been using the name OMAR BAS HASS in all my other documentations and
official representations, up to the present, except for the aforementioned erroneous
PhilHealth registration;

5. That the name OMAR BAS HASS is my true and correct name;

6. That such erroneous name of OMAR AMBOY and such erroneous date of birth of 18
November 1970 in the PhilHealth system should be corrected by virtue of this Affidavit and
my Certificate of Marriage, as attached and above-mentioned;

7. That I, nonetheless, attest and declare that the erroneous name of OMAR AMBOY as
incorrectly registered with the PhilHealth system pertains to me, OMAR BAS HASS, as one
and the same person;

8. That this Affidavit of One and the Same Person is executed for all legal intents and purposes it
may serve.

IN WITNESS WHEREOF, I have signed this affidavit on this 2nd day of November 2022 at
Zamboanga City.

OMAR BAS HASS

Affiant

SUBSCRIBED AND SWORN to before me this 2nd day of November 2022, affiant who is
personally known to me, and/or has satisfactorily proven to me his identity through competent evidence,
exhibiting his government ID no. _______________ issued at ____________________ on _____________.

Doc. No. ;
Page No. ;
Book No._III;
Series of 2022.