REPUBLIC OF THE PHILIPPINES)

CITY OF ZAMBOANGA .. .. . . . . .) S.S.

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AFFIDAVIT OF NON-RECEIPT

I, MA. LOURDES E. SOLIS, of legal age, Filipino, single and a resident of Block 3, Lot 4,
HB Homes Subdivision Duramos Drive, Barangay Pasananca, Zamboanga City, after having been
sworn to in accordance with law, hereby depose and state:

1 That sometime in 2010, I applied for membership with Philippine Health

Insurance Corporation, this City;

2 That I started paying the membership fee and was not issued an Identification
Card by the same company;

3 That when I seek for foreign employment sometime in 2014, I failed to settle my
annual contribution due to thereto;

4 That I execute this Affidavit freely and voluntarily to attest to the truthfulness of
the foregoing facts and for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand and affixed my signature this
________________________________ at Zamboanga City, Philippines.

MA. LOURDES E. SOLIS

Affiant

SUBSCRIBED AND SWORN to before me on the above-written date and place.