Republic of the Philippines

City of _____________
) S.S.
I, ______________, Filipino, of legal age, single and a resident of
________________________________, after being duly sworn to in accordance with law,
hereby depose and state:
1. That ;
2. That ;
3. That ;
4. That I am executing this affidavit for the purpose of (i) x x x , (ii) x x x, and (iii)
attesting to the truth and veracity of the foregoing statements and facts, and; (iv) for
whatever legal purpose this may serve.
IN WITNESS WHEREOF, I have hereunto set my hand this_________ at_____________,
_______ City.
SUBSCRIBED AND SWORN TO before me a Notary Public for and in the ______________, affiant
avowing under penalty of law as to the contents hereof and exhibiting to me his/her TIN/SSS
No. ______________.
Doc. No.
Page No.
Book No.
Series of 20_______.

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