REPUBLIC OF THE PHILIPPINES)

CITY OF TAGBILARAN )S.S.

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AFFIDAVIT OF INCOME DECLARATION

I, EDGARDO N. GURRE, Filipino, of legal age, married, and a resident of

Manga, Tagbilaran City, Bohol, Philippines, after having sworn in accordance with law,
depose and say that:

1. I am a bona fide PhilHealth member with PIN: 19-026365326-6;

2. I have not been gainfully employed as I am a retired mechanical engineer and I

have only relied on my wife for financial support who receives income as a
seafarer;

3. The whole family depends on the monthly income of my wife for support;

4. I am executing this Affidavit-Declaration to comply with the PhilHealth

requirement in the determination of the applicable premium bracket to be
imposed by them and for all legal purposes this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 14 th day of January

2020 in the City of Tagbilaran, Province of Bohol, Philippines.

EDGARDO N. GURRE
Affiant-Declarant
PhilHealth No. 19-026365326-6
Issued by: PhilHealth

SUBSCRIBED AND SWORN TO BEFORE ME, this 14 th day of January, 2020, in the
City of Tagbilaran, Province of Bohol, Philippines.

Doc. No. 29;

Page No. 4;
Book No. 1;
Series of 2020.
ATTY. JOHN JERIC S. LIM
NOTARY PUBLIC COMM UNTIL DEC. 31, 2021
Attorney’s Roll No. 70690
IBP No. 095579 for 2020
PTR No. 7940547 for 2020
TIN No. 278608672
NCS No. 2020-21