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REPUBLIC OF THE PHILIPPINES)

CEBU CITY )S.S.

AFFIDAVIT

I, Dr. Rodrigo S. Hipoll III of legal age, Single and a resident of Butuan City,
Agusan Del Norte after having duly sworn to in accordance with the law hereby depose
and says:

1. That I am the Consignee of the 4 pcs Said to Oxygen Concentrator under


awb no. under DHL 5137939240 From China.

2. That the above shipment is my first shipment and will be filed under
informal entry

3. That I am executing this affidavit to attest to the veracity of the foregoing


statement and for all legal intents and purpose this may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this November


16, 2021 in Cebu City, Philippines.

Dr. Rodrigo S. Hipol III


AFFIANT

SUBSCRIBED AND SWORN to before this of November 16, 2021 at Cebu City
Philippines, affiant exhibited to me his Philhealth license no . 020250670053
issued On July 30, 2020 at Agusan Del Norte.

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