Republic of the
Philippines )
City of ___ ) Sc.
AFFIDAVIT OF ECONOMIC STATUS
I, AAA, of legal age, Filipino
citizen and with residence address at 143 Brgy IloveYou, Manila, after having
been sworn to in accordance with law, do hereby depose and state, that:
1. I am applying for
Violet Card at XXX Medical Center, Manila, to support my medication and in
connection therewith, I am required to submit a sworn statement of my economic
status, hence this affidavit;
2. I am solo parent
with one minor child still studying;
3. I am not getting
any financial support from the father of my minor child;
4. I am unemployed
and our sole source of income is my sari-sari store located in our residence at
143 Brgy IloveYou, Manila;
5. I am earning Two
Hundred Pesos (P200.00) daily income from my sari-sari-store, of which we are
getting our daily expenses, and payment for utility bills and rental fee;
6. I am executing
this affidavit to attest to the truth of the foregoing
facts and for purposes of applying for issuance of Violet Card issued by XXX Medical Center.
AND FURTHER AFFIANT
SAYETH NAUGHT.
IN
WITNESS WHEREOF, I
hereby signed this Affidavit on this ____day of ______________20__ in the City
of ________________ on ______________.
AAA
Affiant
Signed in the Presence of:
______________________________ _____________________________
REPUBLIC OF THE
PHILIPPINES )
CITY OF
_______________________) Sc.
JURAT
SUBSCRIBED AND SWORN to before me
this___________________________ in the City of _____________, affiant exhibiting to me his/her government issued identification card No.
__________________________________, issued on _________________, issued at
______________.
NOTARY PUBLIC
Doc. No. :_______
Book No. :_______
Page No. :_______
Series of :2019.
