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Republic of the Philippines )

City of Tagbilaran ) S.S.

JOINT- AFFIDAVIT OF TWO DIS-INTERESTED PERSONS

We, ESTERLITA S. BANSAG and ARSENIO SAROMINES MIER, both married,


Filipinos, of legal ages, and residents of Barangay Dao, Tagbilaran City, Bohol,
respectively, having been duly sworn in accordance with law, hereby depose and state:

1. We both personally know the person of VEOLITO PAIT as his family had been
close friends to us;

2. That we also know that he used the name VEOLITO PAIT in all his public and
private documents and he is known in the community as VEOLITO PAIT;

3. That as reflected in his Birth Certificate, his name appears to be VEOLITO PAIT;

4. That he had been married to MARICHU SANO NILUAG, and as a result thereof,
his wife had been using the married name, MARICHU NILUAG PAIT;

5. That as far as we are concerned, we know his mother to be, LUCRESIA


GAMBUTA PAIT and he had an unknown father, therefore, he is registered as an
illegitimate child in his Certificate of Live Birth;

6. That as a result of such registration, his Certificate of Live Birth did not bear a
middle name;

7. That we hereby attest that the names VEOLITO PAIT and VEOLITO GAMBUTA
PAIT, REFER TO ONE AND THE SAME PERSON who is our close family friend
for a long time now;

8. That we are not related by affinity or consanguinity to the said VEOLITO PAIT
nor are we given reward for executing this affidavit. The same is not executed to
evade any criminal, civil, or administrative liability or to obstruct justice;

9. That we execute this Affidavit to attest the veracity of the above-statements, for
the purpose of registering his beneficiaries with the PhilHealth as well as claim
benefits thereto, to his known name from VEOLITO GAMBUTA PAIT to the name
VEOLITO PAIT and for any other legal purpose that this Affidavit may serve best.

IN WITNESS WHEREOF, we have hereunto set our hands this ______________


at Tagbilaran City, Bohol, Philippines.

ESTERLITA S. BANSAG ARSENIO SAROMINES MIER


Affiant Affiant
Social Security System ID No. 33-2629271-9 Office of the Senior Citizen’s Affairs No.
DAO-008542

SUBSCRIBED AND SWORN TO before me this ____________ at


Tagbilaran City, Bohol, Philippines. Affiants exhibited to me their valid government
issued identification cards.

DIANE CHRISTI M. GARCIA-CLARABAL


PUBLIC ATTORNEY
(PURSUANT TO R.A. 9406)