Republic of the Philippines )

Province of Albay ) S.c.

Municipality of Daraga )

x--------------------------------x

AFFIDAVIT OF INCOME DECLARATION

I, SARAH ELIZABETH B. LUNAS, of legal age, Filipino, single and a resident of Manga, Oas, Albay,
after having been sworn in accordance with law, hereby depose and state:

1. That I am a member of PhilHealth with PhilHeath No. 10-050274426-1;

2. That I am self-employed and earning a monthly income of PhP10,000.00;

3. That I am executing this affidavit as required by PhilHealth.

IN WITNESS WHEREOF, I hereunto set my hand this 4th day of November, 2022 at Ligao City,
Philippines.

SARAH ELIZABETH B. LUNAS

Affiant

SUBSCRIBED AND SWORN TO before me this __________________________ at Ligao City,

Philippines.

Doc No. ______;

Page No. _____;

Book No. _____;

Series of 2022.