REPUBLIC OF THE PHILIPPINES)

City of Mandaue ) S. S.
x-------------------------------------------x

AFFIDAVIT OF CLOSED SHOP

I, Delfin Jover Empe, Filipino, of legal age, married, and a resident of Zone 1-122 San
Antonio Street, Looc, Mandaue City, Cebu, Philippines, after having been duly sworn to in
accordance with law, do hereby depose and state that:

1. I am currently filing a claim with the JSU Fund;

2. That I was affiliated/employed through Pilipinas Crown between the years 2002 to
2005;

3. To the best of my personal knowledge and recollection, Pilipinas Crown, the agency
that I was affiliated with between the years 2002 to 2005, is currently closed, defunct,
and non-operational;

4. As such, I execute this Affidavit to certify or attest to the truth of the foregoing facts
and for whatever legal purpose that this Affidavit may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 16th day of May, 2023 at
Mandaue City, Cebu Philippines.

Delfin Jover Empe

Affiant
National ID No. 3813-9487-4376-0570

SUBSCRIBED AND SWORN to before me this 16th day of May 2023, at Mandaue City,
Philippines, by the Affiant whom I have identified through competent evidence of above-mentioned.

Doc. No. _____;

Page No. ____;
Book No. ___;
Series of 2023.