REPUBLIC OF THE PHILIPPINES)

CITY OF LUCENA ) SS.

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

AFFIDAVIT OF NON-ACCEPTANCE

I, TSgt. JOMAR ENGLIS NARVASA (Ret.), of legal age, Filipino, married, and a
resident of Sitio Carsada, Looc, Nasubu, Batangas, Philippines, after having been duly
sworn in accordance with law, hereby depose and state:

1. I am already a Philippine Army Retiree having retired (Optional Retirement) from

the Philippine Army effective January 1, 2023;

2. That I am a bona fide member of Armed Forces and Police Mutual Benefit
Association Incorporated (AFPMBAI);

3. That I have not receive my policy contract from the AFPMBAI since my
membership up to the present date;

4. That I am executing this Affidavit of Non-Acceptance of my AFPMBAI Policy

Contract to support the processing of my TERMINAL BENEFIT and CASH
SURRENDER VALUE CLAIMS from the AFPMBAI;

5. That I executed this affidavit in order to attest to the truth of the foregoing and for
whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 5 th day of January 2023
at Lucena City, Philippines.

JOMAR ENGLIS NARVASA

Affiant
AFPCS NR. OTAG-EP-823198-272758

SUBSCRIBED AND SWORN to before me, this 5th day of January 2023 at Lucena
City, Philippines.

ATTY. CHRISTOPHER P. JUNIAR

Notary Public
Attorney’s Roll No. 77224
PTR No. 3416706 01/03/2023 Lucena City
IBP O.R. No. 256546 12/31/2022 Pasig City
Tax Identification No. 277-604-758
MCLE exempted, pursuant to
MCLE Governing Board Order No. 1, s, 2008