Republic of the Philippines)

Province of Masbate )
City of Masbate )
x---------------------------------x

AFFIDAVIT OF INCOME

I, _________________________, of legal age, single/ married/ widow/ widower,

Filipino, and a resident of __________________________________( ADDRESS), after
having sworn in accordance with law, do hereby depose and state:

1. That I am a bona fide member of PhilHealth with membership no.

____________________;
2. That I am self-employed and earning a monthly income of P__________
pesos;
3. That I am executing this Affidavit as required by PhilHealth.

IN WITNESS WHEREOF, I hereunto affix my signature this

_____________________ at Masbate City, Masbate, Philippines.

________________________
Affiant

SUBSCRIBED AND SWORN TO before me this ______________________at

Masbate City, Masbate, Philippines.

Doc No. ____;

Page No. ____;
Book No. ____;
Series of 2020.
Republic of the Philippines)
Province of Masbate )
City of Masbate )
x---------------------------------x

AFFIDAVIT OF INCOME

I, RICHIAR MAE CAPILI, of legal age, single, Filipino, and a resident of Brgy.
Nursery, Masbate City, Masbate, after having sworn in accordance with law, do hereby
depose and state:

1. That I am a bona fide member of PhilHealth with membership no. 10-

251918633-8;
2. That I am currently employed in the Department of Labor and Employment as
PEIS coordinator, a job order position;
3. That I am earning a monthly income of eight thousand (P8,000.00) pesos;
4. That I am executing this Affidavit as required by PhilHealth.

IN WITNESS WHEREOF, I hereunto affix my signature this 12th day of

December, 2019 at Masbate City, Masbate, Philippines.

RICHIAR MAE CAPILI

Affiant

SUBSCRIBED AND SWORN TO before me this 12th day of December, 2019 at

Masbate City, Masbate, Philippines.

MA. THERESA A. LEGASPI- VALENCIA

Public Attorney II
Pursuant to R.A. 9406

Doc No. ____;

Page No. ____;
Book No. ____;
Series of 2019.