Republic of the Philippines

Province of Cebu
Municipality of San Remigio
BARANGAY POBLACION

OFFICE OF THE PUNONG BARANGAY

CERTIFICATE OF INDIGENCY

TO WHOM IT MAY CONCERN:

This is to certify that MARIE S. URSAIS, of legal age, married and is a bonafide
resident of Purok Mangga, Poblacion, San Remigio, Cebu, Philippines.

This certifies further that the above-mentioned name is a person of good moral
character, a law-abiding citizen and has neither nor criminal record/s in this barangay as
of this date and is one of the INDIGENT fellow in our community.

This certification is being issued upon the request of the above-named person in
connection with his/her application/requirement to respective government offices
concerned to obtain MEDICAL ASSISTANCE and for whatever legal purpose it may
serve.

Issued this 11th day December, 2007 at Barangay Poblacion, San Remigio,
Cebu, Philippines.

MARIO S. TINO
Punong Barangay

NOT VALID WITHOUT OFFICIAL SEAL