Republic of the Philippines )

City/Municipality of __________ )
Province of_________________) S.S.

AFFIDAVIT OF INCOME DECLARATION

I, ____________________, Filipino, of legal age, single and with residence address at

Sto. Rosario, Brgy. Jagobiao, Mandaue City, Cebu, after having been sworn to in accordance
with law, do hereby depose and state: THAT –

1. I am self-employed as I have no employer other than myself and derive income from my
physical and mental efforts as a motorcycle “habal-habal” driver;

2. As motorcycle “habal-habal” driver, I earn Two Hundred Pesos to Four Hundred Pesos
per day or on the average, Six Thousand Pesos per month.

3. I am making this affidavit to attest to the truth of the foregoing facts and to support my
application for voluntary payment/contribution with Philhealth.

IN WITNESS WHEREOF, I have hereunto set my hand this _________________day of

_______________, 2020 in ____________________________, Philippines.

____________________
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME this ____ day of _________, Affiant

exhibiting to me his ________________________ issued
_____________________________________.

NOTARY PUBLIC
Doc. No. _____;
Page No. ____;
Book No. ____;
Series of 2020.