REPUBLIC OF THE PHILIPPINES)

IN THE CITY OF DAVAO)S.S.

X………………………………………….X

AFFIDAVIT OF AMENDMENT

I, XU MOU ZE, of legal age, Chinese, married and with a residence of #170B
Basilan, Circle, Tawi-tawi St., Phase 2, West Insular Village, Lanang, Davao City,
Philippines, after having been duly sworn in accordance with law, hereby depose
and say that:

1. I am one and the same person who known as ADAN CO., a member of
Philippine Health Insurance Corporation with a identification card number
16-050041851-3;

2. The signature in my PhilHealth ID bear my current and actual signature

presented in any form of identification card such as passport and Bureau
of Immigration;

3. I warrant and avow to update or amend my PhilHealth application to

change ADAN CO to my real name XU MOU ZE of the aforesaid
identification card;

4. I am executing this Affidavit to attest to the truth of the foregoing facts

and to apprise the proper authorities concerned of the same for all other
legal intents and purposes it may served.

IN WITNESS WHEREOF, I have affixed my signature this

_______________ at Davao City, Philippines.

XU MOUZE
Affiant

SUBSCRIBED AND SWORN to before me this ________________ at

Davao City, Philippines. Affiant exhibiting to me his Chinese Passport issued to
replace by the PRC in No. G35100637.

Doc. No. ____;

Page No. ____;
Book No.___;
Series of 2021.