Republic of the Philippines )

Province of Negros Oriental) S.S.

Municipality of Sibulan)

AFFIDAVIT OF UNDERTAKING

I, MARYGLO H. JANSSEN, of legal age, Filipino, widow and a resident of

Looc, Sibulan, Negros Oriental, after having been sworn to in accordance with
law, do hereby depose and state that:

1. I am the biological mother and guardian of minor ANGELIQUE

BEATRIX DOUTZEN H. JANSSEN;

2. That ANGELIQUE BEATRIX DOUTZEN H. JANSSEN is the

beneficiary/ITF of GERARDUS MARIA JANSSEN who died sometime on
September 30, 2021 at Negros Polymedic Hospital who is an Account Holder at
PNB with Account No. 308610189297;

3. That I, MARYGLO H. JANSSEN, being the wife of the late

GERARDUS MARIA JANSSEN and biological mother and guardian of minor
ANGELIQUE BEATRIX DOUTZEN H. JANSSEN, will process, claim and receive
whatever deposits/benefits of the late GERARDUS MARIA JANSSEN is entitled
at PNB;

4. That I, undertake that the proceeds that I may receive at PNB from
the deposits/benefits of the late GERARDUS MARIA JANSSEN at PNB will be
utilized for the benefit of ANGELIQUE BEATRIX DOUTZEN H. JANSSEN, and I
shall take full responsibility from whatever claims that may arise from any
parties;

5. I am executing this affidavit to attest to the truthfulness and

veracity of the foregoing facts.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 13 th

day of October 2021 in Sibulan, Negros Oriental, Philippines.

MARYGLO H. JANSSEN
Affiant

SUBSCRIBED AND SWORN to before me, a Notary Public, on this 13 th

day of October 2021, for the Municipality of Sibulan and the Province of Negros
Oriental, Philippines, MARYGLO H. JANSSEN, who exhibited before me her
Passport ID No. P6440011A valid until 15 Mar 2028 at Sibulan, Negros
Oriental, and WHO SIGNED IN MY PRESENCE the foregoing document
(Affidavit of Undertaking), and who avows under PENALTY OF LAW to the
whole truth of the contents of the same.

Doc No. 229;

Page No. 47;
Book No. IV;
Series of 2021.