Republic of the Philippines ))

City of Calbayog )) s.s.

AFFIDAVIT TO SUPPORT CLAIM

I, CELSO E. DATA, Filipino, of legal age, married, and a resident of Barangay East
Awang, Calbayog City, Samar, Philippines, after having been duly sworn to in accordance
with law, hereby depose and state, that--

1. I intend to commence a Small Claims Action against NOEMI ILAGAN

SINGZON, of legal age and a resident of Avelino Street, Barangay Central,
Calbayog City;

2. I am a creditor to SINGZON for an amount of Php 160, 000.00 sometime in

2017.

3. In payment of her obligation, she issued a check Pay to the Order of Cash in the
amount of 160, 000.00 dated December 31, 2017 with AUB Bank Calbayog
Branch;

4. The said check bears an alteration in its Date to which she affixed her
countersignature.

5. I presented the said check on January 03, 2018, but the bank dishonored the
same for having alteration. I was advised then to talk to the issuer to issue
another check for same purposes.

6. I communicated the same to the debtor but seems that she was not interested
to settle it and was just told to proceed with the filing of a case;

7. I have been reaching out to her for several times but the possible settlement is
unavailing, thus this commencement of an action;

8. I am executing this Affidavit to attest to the truth of the foregoing facts and to
to support my claim in the filing of an Action in the proper court;

IN WITNESS WHEREOF, I have hereunto set my hand this 2nd day of March
2018, at Calbayog City, Philippines.

CELSO E. DATA
Affiant
Driver’s License: H02-92-029051

SUBSCRIBED AND SWORN TO BEFORE ME, this 2nd day of March 2018, at
Calbayog City, Philippines.

ATTY. ALJUN B. DIAZ

Public Attorney I
Pursuant to RA 9406

Doc. No. 571;

Page No. 05;
Book No. II
Series of 2018