REPUBLIC OF THE PHILIPPINES )

Tagbilaran City ) S.S.

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AFFIDAVIT

I, CHARLA ENTERINA, of legal age, Filipino, resident of San Roque Baclayon,

Bohol, Philippines, after having been duly sworn under oath, do hereby declare:
1. I am the authorized representative of St. Jude Hospital Corp. located at C.P.G.
Avenue, Tagbilaran City, Bohol, Philippines;

2. St. Jude Hospital Corp. is a Hospital engaged in the rendering of medical and
pharmaceutical related services;

3. Annabella Copoquian’s mother, Evangelista Tan Apat, was admitted to St. Jude
Hospital on April 26, 2019, and was discharged on April 30, 2019;

4. On April 30, 2019, Miss Annabella Capoquian executed a promissory note

obligating herself to pay the outstanding balance of their hospital bill, owing to
St. Jude Hospital, due on May 02, 2019;

5. The promissory note became due on May 02, 2019, however the account was
never settled or paid, and despite of several demands and extensions given, the
account remained unsettled;

6. A Demand Letter dated June 10, 2019 and a Final Demand letter dated June 19,
2019 were sent to Annabella Copoquian, but to no avail;

7. I am executing this affidavit to support the filling of a Small Claims action against
to ANABELLA CAPOQUIAN.

8. This affidavit is executed freely and voluntarily based on above facts and
circumstances which are established upon authentic documents and hospital
records.

IN WITNESS WHEREOF, I have hereunto affixed my signature on this 17 th day of

October 2019, at Tagbilaran City.

CHARLA ENTERINA
Affiant
ID No. __________________________

SUBSCRIBED and SWORN to before me this 17 th day of October 2019, at

Tagbilaran City, presenting to me the above evidence of identity. I hereby certify that I
have personally examined the above-named affiant and that I am satisfied that the
foregoing statements were given by him voluntarily and of his own free will.

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