Republic of the Philippines )

Calamba Misamis Occidental )s.s.

AFFIDAVIT

I, X, 47 years old, Filipino citizen and a resident of Poblacion, Sapang

Dalaga, Misamis Occidental, after having been sworn in accordance with law,
hereby depose and say:

1. That I applied for a Life Insurance with PhilLife Financial with policy
number !;

2. That it is a five (5) year contract with effective date on June 1, 2015
with a monthly deduction of Php 300.00;

3. That the insurance bill payment is collected directly from our payroll
through the Payroll Division of Region X Department of Education;

4. That I intend to stop payment of the said insurance policy and thus,
the Payroll Division of Region X Department of Education shall cease
to deduct the said amount from my salary.

That I execute this Affidavit freely and voluntarily to attest to the

foregoing facts and for whatever legal purpose this may serve.

FURTHER, Affiant sayeth none.

IN WITNESS WHEREOF, I hereunto set my hand this 4 th day of

September 2017 at Calamba Misamis Occidental, Philippines.

X
Affiant

SUBSCRIBED AND SWORN to before me this 4th day of September

2017 at Calamba Misamis Occidental, Philippines.