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 ______________.
Signed in the Presence of:
REPUBLIC OF THE PHILIPPINES )
CITY OF _______________________) Sc.
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 ______________.
Doc. No. :_______
Book No. :_______
Page No. :_______
Series of :2019.