REPUBLIC OF THE PHILIPPINES)

CITY OF BACOLOD ) S.S.

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

AFFIDAVIT OF NON-ACCEPTANCE

I, JSUPT SAMSON P ABAYGAR (Ret), of Legal Age, Filipino, Married

and resident of Blk. 2 Lot 18 Hermilinda Homes Mansilingan Bacolod City,
Philippines, After having been duly swore to in accordance with law, do
hereby depose and say;

1. That I am already a BJMP Retiree, having retired (Optional

Retirement) from the Bureau of Jail Management and Penology effective 01
May 2013;

2. That I am a bonafide member of the Armed Forces and Police Mutual

Benefit Association Incorporated (AFPMBAI);

3. That I have not received my policy contract from the AFPMBAI since
my membership up to the present date;

4. That I am executing this Affidavit of Non-Acceptance of my AFPMBAI

Policy Contract to support the processing of my TERMINAL BENEFIT and CASH
SURRENDER VALUE claims from the AFPMBAI;

5. As such, I am executing this affidavit to attest the truthfulness of the

foregoing facts;

IN WITNESS WHEREOF, I have hereunto set my hand this ____Day

of March 2017 in Makati City, Metro Manila, Philippines.

JSUPT SAMSON P ABAYGAR

Affiant

TIN No. 132-937-015

SUBCRIBED AND SWORN TO before me this ________ in Bacolod

City, Philippines.

Doc. No. _____;

Page No._____;
Book No._____;
Series of _____;