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Form No. 1--Affidavit of Support for PhilHealth

(Affidavit of Support for PhilHealth)

Republic of the Philippines)
Province of ____________________)S.S.
City/Municipality of _____________)
x - - - - - - - - - - x

AFFIDAVIT OF SUPPORT

I, _____________, Filipino, (single / married / widow), of legal age, and a resident of _____________, Philippines, having been duly sworn in accordance with law, hereby depose and state:

That I am presently applying for membership of Philhealth;

That I am declaring my (father/mother), _____________, ______ years old as one of my legal dependents who is dependent upon me for regular support;

That I am executing this Affidavit for the purpose of receiving benefits from PhilHealth for the aforementioned dependent;

That I am fully aware that any false statement or misrepresentation as to the facts mentioned above will be a ground for automatic disapproval of the PHILHEALTH application.

IN WITNESS WHEREOF, I have set my hand this _____________ in the City of _____________, Philippines.

AFFIANT

(JURAT)

 

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