REPUBLIC OF THE PHILIPPINES)

MUNICIPALITY OF INABANGA )
PROVINCE OF BOHOL) ) S.S.
x------------------------------------------------x

AFFIDAVIT
(RE: for JOINT “OR” ACCOUNT)

I, FELISA S. BERTULFO, of legal age, Filipino, single, and a resident of

Poblacion, Inabanga, Bohol, after having been duly sworn to in accordance with law,
depose and state:

1. That I am the co-depositor under SA No. 018-0201-018481-8 which is joint “or”

account, with the late LEANDRO SR. C. SALAZAR who died intestate on July 22, 2021
his Death Certificate is hereto attached and marked as Annex “A”;

2. That we maintained said joint “or” account at FCB – INABANGA Branch;

3. That in view of his death, I desire to withdraw the amount under SA No. 018-0201-
018481-8 with the conformity of his heirs who have signified their consent or no
opposition to my intended withdrawal by affixing their signature herein;

4. That I hold the FIRST CONSOLIDATED BANK and its directors and employees free and
harmless from any liability or damage and I take full responsibility should there is / are
claim/s from any person whomsoever on a portion or whole amount of the withdrawn
deposit.

AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto set my hand this _________________ in

Inabanga, Bohol, Philippines.

FELISA S. BERTULFO
Passport ID: HH453610

With the conformity of the heir/s:

_____________________
LEANDRO J. SALAZAR, JR.

Signed in the presence of:

_______________________ ________________________

SUBCRIBED AND SWORN TO before me this ____________________ in Inabanga,

Bohol, Philippines, affiant exhibiting to me her valid proof of identification. The above-
named affiant known to me to be the same person who executed the foregoing
instrument and who made an oath before me respecting the truth of the foregoing
declarations and he acknowledged to me the foregoing instrument was freely and
voluntarily executed by him.

Doc. No. _____;

Page No._____;
Book No. 12;
Series of 2023.