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Republic of the Philippines )

City of Bacolod )ss.


x----------------------x

AFFIDAVIT

I, JENNIFER M. MELLIZA, of legal age, single, Filipino citizen and a resident


of Blk. 6, Lot 8,Grandville II Subd., Brgy. Mansilingan, Bacolod City, Philippines after
having been sworn in accordance with law, hereby depose and say:

That I am an employee of the Provincial Government of Negros Occidental


under the Public Affairs Division, Office of the Governor for a period of nine years;

That I serve as District Coordinator for the First District of the Province for the
Barangay Insurance Program for Barangay Officials, Selected Employees and
Tanods;

That I have, however, inadvertently omitted the name of NELSON M. LIM, Jr.,
Brgy. Tanod from Barangay Suba, Calatrava from the Masterlist of the January 1
March 31, 2010 Policy Period of Barangay Tanods;

That prior to this, NELSON M. LIM, Jr. is originally included in the January 1
March 31, 2010 coverage having been enrolled since the inception of the Program in
October 2002;

That what prompted me to accidentally omit him from the list was his death
on January 4, 2010 as reported by the Punong Barangay of Brgy. Suba;

That the beneficiaries of Mr. Lim may not avail of any insurance claim if his
name is excluded in the coverage while in truth and in fact he should have been
included in the list and his beneficiaries are entitled for insurance claims;

THIS AFFIDAVIT IS NOW EXECUTED in order to attest to the truthfulness of the


foregoing facts, and in order to attest to the fact that NELSON M. LIM, Jr. is originally
included in the January 1 December 31, 2010 Masterlist of the Barangay
Insurance Program for Barangay Tanods, as well as for all other legal purposes it
may serve .

In truth and witness whereof, I have hereunto set my hand this


__________________, in Bacolod City, Philippines.

____________________________
JENNIFER M. MELLIZA
CTC No.06385763
Issued February 18, 2010
Issued at Bacolod City

BEFORE ME, in the place and on the date abovementioned, personally appeared the Affiant
with her above-described residence certificate; She acknowledged to me that the foregoing narration
of facts is true and correct of her own personal knowledge.

Witness my hand and seal.

Doc. No.______
Page No.______
Book No. _____
Series of ______