AGREEMENT

KNOW ALL MEN BY THESE PRESENT:

This AGREEMENT made and entered into by and between: DIVINE MERCY HOSPITAL with postal
address at #25 High School Drive, San Vicente West, Urdaneta City, Pangasinan, represented
herein by JASMIN RAMIREZ, of legal age, Filipino, single, Billing Officer and a resident of Zone 2,
Pinmaludpod, Urdaneta City, Pangasinan, hereinafter called the HOSPITAL, and JEAN CORPUZ
and OLDARICO CORPUZ of legal ages, Filipinos, and residents of Palina West, Urdaneta City,
Pangasinan.

WITNESSETH:

That on November 24, 2022, the PATIENT gave birth to her child at the HOSPITAL and has to pay
Php 137,875.00 as her Hospital Bills.

That the HOSPITAL agreed that the PATIENT will pay her Hospital Bills in installment, subject to
the following terms and condition, to wit

1. The PATEINT shall pay Php 95,000.00 as partial payment on the date of this agreement.

2. The PATIENT will pay the remaining balance in the amount of Php. 42,875.00 within 1 month.

3. The HOSPITAL shall have the right to enforce payment of the Hospital Bills, by taking legal
remedies, in case the PATIENT fails/refuses to pay her obligation.

4. Patient has a collateral of LAND TITLE with TCT number 292421 which can be transferred
under Dr. Leo Tarectecan if the remaining balance is not paid within a year. (November 24,
2022)

DIVINE MERCY HOSPITAL JEAN CORPUZ

BY: JASMIN RAMIREZ OLDARICO CORPUZ

SIGNED IN THE PRESENCE OF: BEA DE GUZMAN AND JOBEN ARAÑA

REPUBLIC OF THE PHILIPPINES )
PROVINCE OF PANGASINAN )
S.S CITY OF URDANETA )
X---------X

IN WITNESS WHEREOF, the PATIENT have hereunto set their hands this 24 th day of November,
2022 at Urdaneta City, Pangasinan.

BEFORE ME, a Notary Public for and in Urdaneta City, Pangasinan, personally appeared the
PARTIES, who are known to me to be the same persons who executed the foregoing instrument
and acknowledged under oath that the same is their own free will and voluntary act and deed.

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