HQP-HLF-217

REPUBLIC OF THE PHILIPPINES)

___________________________ ) S.S.

AFFIDAVIT OF PROOF OF SERVICE

I, __________________________________, Filipino, of legal age, with postal

address at _____________________________________________, after having been
duly sworn in accordance with law, do hereby depose and state:

1. That I personally delivered the Notice of Cancellation (NOC) dated

_______________ addressed to Mr./Ms. ____________________________
with postal address at ___________________________________________
_________________ on _______________;

2. That I further attest that:

□ a. The addressee received the NOC as shown by his/her signature on the

file copy of the NOC.

□ b. The addressee received the NOC but refused to sign on the file copy of
the NOC.

□ c. The addressee was at the address given above but he/she refused to
receive the NOC. Thus, service was done by leaving a copy of the NOC
at the gate/doorstep of the addressee & informing him/her of the same.
Attached hereto is the file copy of the NOC.

□ d. The affiant went to the addressee's place on the date above stated,
within the hours from 8:00 AM to 5:00 PM, but the addressee was not
there. Thus, the notice to the addressee was served upon her through
her (relation to the person who received), (age), who at the time was
living at the same address. A copy of the NOC is hereto attached.

□ e. The affiant went to the addressee's place on the date above stated,
within the hours from 8:00 AM to 5:00 PM, but the addressee was not
there. The affiant tried serving the NOC to (a person living with the
addressee) but the latter refused to receive the NOC. Thus, service of
the NOC was made to the addressee by leaving a copy thereof at their
gate/doorstep and informing the occupant found therein of the same. A
copy of the NOC is hereto attached.

□ f. The affiant went to the addressee's place on the date above stated,
within the hours from 8:00 AM to 5:00 PM, but the place is abandoned.
Thus, service of the NOC was made to the addressee by leaving a
copy thereof within the premises. A copy of the NOC is hereto attached.

□ g. The affiant went to the addressee's place on the date above stated,
within the hours from 8:00 AM to 5:00 PM, but nobody is around to
receive the NOC. Thus, service of the NOC was made to the
addressee by leaving a copy thereof within the premises. A copy of the
NOC is hereto attached.

□ h. After due diligent search for the above-stated address, the same
cannot be located.

(November 2012)
 3. (In cases of paragraphs b to h above) That the NOC was also served through
registered mail posted on (date of mailing) at _____________________
Post Office under Registry Receipt No. ___________

4. That I am executing this affidavit to attest to the truth of the foregoing facts.

IN WITNESS WHEREOF, I have hereunto set my hands on this _______th day

of ________________ at _______________________.

AFFIANT
(ID) No.
Date of Issue :
Expiry Date :
Place of Issue :

WITNESSES:

_______________________________ _______________________________
Signature Over Printed Name Signature Over Printed Name

ACKNOWLEDGMENT

SUBSCRIBED AND SWORN to before me in the City/Municipality of

_____________, this ____ day of _______________, 20___ personally appeared
Mr./Ms. ________________________________, who has satisfactorily proven to me
his/her identity through his/her _____________ with I.D. No. ____________ valid until
_________, that he/she is the same person who executed and voluntarily signed the
foregoing Affidavit of Proof of Service, which he/she acknowledged before me as
his/her free and voluntary act and deed.

The foregoing Affidavit of Proof of Service consisting of ______ (__) pages

including the page on which this acknowledgment is written, has been signed on the left
margin of each and every page by the party and his/her witnesses.

WITNESS MY HAND AND NOTARIAL SEAL on the date and place above
written.

NOTARY PUBLIC

Doc. No. _______;

Page No. _______;
Book No. _______;
Series of ________.

(November 2012)