REPUBLIC OF THE PHILIPPINES)

BATANGAS CITY ) S.S.

AFFIDAVIT

I, LEODIVINA M. BAUAN, married, Filipino, of legal age, with address at Pallocan, Batangas City,
having been duly sworn in accordance with law, hereby depose and state:

1. I am the owner and holder of The Manufacturers Life Insurance Company (Philippines), Inc.
Policy No. 6448285-4

2. Ms. Lorenza Bool is the servicing agent of the aforementioned policy.

3. On the dates set forth below, I delivered to Ms. Lorenza Bool, and the latter duly received from
me, the following amounts representing payment of premium(s) due on my afforested policy:

DATE AMOUNT PREMIUM DUE PROOF OF RECEIPT

P278,000.00 (state PR No. of details of other
document(s) evidencing payment;
if none. state reason(s))

4. However, I subsequently learned (state circumstances of discovery) that my aforementioned

policy lapsed. This came as a total surprised for me as, with my foregoing payments, my above stated
policy should have not lapsed.

5. I am executing this affidavit to attest the truth of the foregoing and to requests The
Manufacturers Life Insurance Company (Philippines), Inc. to honor my payments, in the amounts and
on the dates set forth above, and to place my above-stated policy in force. In the event that the
foregoing are found to be false and untrue, I undertake to immediately pay any amount due and/or
comply with the reinstatement requirements, otherwise my policy(ies) shall be considered lapsed as of
its actual premium due and unpaid, without prejudice to The Manufactures Life Insurance Company
(Philippines), Inc.s right to proceed against me for such falsity.

6. Upon the acknowledgement of my foregoing payments and upon the recognition of my

aforedescribed policy as in force (or reversal of the APL on my aforedescribed policy), I hereby assign to
The Manufacturers Life Insurance Company (Philippines), Inc. any and all rights, interest and causes of
action that I may have or hereafter have against Mr. (Ms.) (agents name) and all parties involved,
arising from the acts and transactions narrated above, and I hereby undertake to appear and testify as a
witness for The Manufactures Life Insurance Company (Philippines), Inc. should the latter so request,
before any court, tribunal or quasi-judicial agency before which the appropriate action(s0 or
proceedings against Mr.(Ms.) (agents name) shall have been brought.

AFFIANT FURTHERSAYETH NAUGHT.

LEODIVINA M. BAUAN
Affiant
 ACKNOWLEDGEMENT

Republic of the Philippines )

Batangas City ) S.S

SUBSCRIBED AND SWORN TO BEFORE ME, in the City of Batangas on this __________________, the
Affiant exhibited to me his/her:

Competent Evidence of Identity Date/Place Issued

ROBERTO IIGO D. SANCHEZ

Notary Public
Until December 31, 2017
Doc No. ____; PTR No. 2576992 01.14.2016 Bats. City
Page No. ____; IBP No. 1011277 01.20.2016 Bats. City
Book No. ____; Roll No. 61644 Serial No. 2016-31
Series of 2016 Zenaida Arcade, 43 M.H. Del Pilar St., Batangas City