REPUBLIC OF THE PHILIPPINES) CITY OF LAOAG ) S.S.

AFFIDAVIT I, _______________________, married to __________________, of legal age, Filipino citizen and a resident of ____________________________, after having been sworn to in accordance with law hereby depose and state that: That I am the absolute owner of a parcel of land of Lot No. 4039 and 4040, containing an area of TWO HUNDRED SEVENTY FOUR [274 sq mts.] SQUARE METERS with a Residential house containing a floor area of EIGHTY EIGHT SQUARE METERS and EIGHTY-THREE DECIMETERS [88.83 sq. mts.] and FIFTY FIVE SQUARE METERS [55 sq. mts], respectively; both situated at ____________________________, declared under Tax Declaration No. ____________________________ for the land and ____________________________for the improvement and ____________________________for the road lot; That, I hereby request the ____________________________to cause the annotation of the said lot in the entry book under my name ; I attest to the veracity and truthfulness of the foregoing statements with my voluntary act and deed for all lawful purposes and legal intent it may serve. IN WITNESS WHEREOF, I have hereunto affixed my signature this ____________ at Laoag City, Philippines.

Affiant

SUBSCRIBED AND SWORN to before me this _______________ at Laoag City, Philippines; presenting to me her identification card, to wit: ______________ and I certify further that I have personally examined the affiant and I am satisfied that he voluntarily executed the same and understood the contents thereof.

Doc. No. ___; Page No. ___; Book No. ___; Series of 2013.