JOINT AFFIDAVIT OF TWO DISINTERESTED PERSONS

Republic of the Philippines )

Province of ____________ ) S.S.
City/Municipality of _____ )

That we – __________________, Filipino, of legal age,

single/married, and a resident of _____________________and
__________________, Filipino, of legal age, single/married, and a
resident of _____________________, after having been duly sworn
to in accordance with law, hereby depose and say:

That we personally know one ____________________, as

reflected in his birth certificate issued by the Philippine Statistics
Authority (PSA), Filipino, of legal age, single/married, and a resident
of _________________________;

That we likewise know that herein subject is a member of

Philippine Health Insurance Corporation with PhilHealth Number
_________________________;

That he has been living with his common-law wife

_____________________ and their three children,
_____________________, _____________________and
_____________________, all born out of wedlock, at
_____________________;

That in the Certificates of Live Birth of both

_____________________and _____________________, issued by
the Office of the Civil Registrar General, the name of their father is
incorrectly reflected therein as _____________________, instead of
_____________________;

That we execute this affidavit freely and voluntarily to attest to

the fact that _____________________, as reflected in the
Certificates of Live Birth of _____________________and
_____________________, and _____________________, as
reflected in his birth certificate issued by the PSA and recorded in the
Member Data Record of Philippine Health Insurance Corporation,
refer to one and the same person;

That we execute this affidavit further in support of

_____________________ request to include his children,
_____________________, _____________________, and
_____________________, in his list of legal PhilHealth beneficiaries;

1
 IN WITNESS WHEREOF, we have hereunto set our hands this
th
25 day of November, 2018 at the City of Tagbilaran, Philippines.

________________________
Affiant
[ID No. ___________]
[Issued by ________]

________________________
Affiant
[ID No. ___________]
[Issued by ________]

SUBSCRIBED and SWORN to before me this 25 th day of

November, 2018 at Tagbilaran City, Bohol by affiants who exhibited to
me their respective valid identification documents as shown above.

Doc. No. 610;

Page No. 153;
Book No. _ II ;
Series of 2018.