Republic of the Philippines } City of Davao }s.s.

AFFIDAVIT(Delayed Remittance of Contribution)

I, ANTOINETTE G. PRINCIPE, Filipino, of legal, age, single and a resident of Davao City after being sworn in accordance with law, hereby depose and state THAT:

1. I am a partner for the Law Firm Women in Law – Davao City with principal business address located at 2/F MM Marble Building J.P. Laurel Avenue, Davao City;

2. The firm bears the PhilHEALTH Number 01-600001628-5;3. The firm has two employees, named:

a. MARIVIC MAGDAGASANG BURGOS; andb. MARILN LOGRONIO RECTO;

4. I have failed to remit PhilHEALTH premium contributions of the above – named employees for the period of APRIL to JUNE of 2012 and JULY and AUGUST of 2012 to PhilHEALTH;

5. That the failure is punishable under Republic Act 7875, as amended;

6. I am executing this affidavit to attest to the truth of the foregoing facts and for whatever legal intent and purpose this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of September, 2012, Davao City Philippines

ANTOINETTE G. PRINCIPEAffiant

_________________________

SUBSCRIBED AND SWORN TO BEFORE ME, this _____ day of September, 2012, Affiant exhibited to me her competent proof of identity as shown above.

WITNESS MY HAND AND SEAL on the day above-stated.

Doc No.____;

Page No.___;Book No. ___;Series of 2012.