Republic of the Philippines)

City of Manila ) S.S.

SWORN STATEMENT
I, _________, of legal age, single, and with office address at ___________,
after being sworn to in accordance with law, depose and state that:
. I a! the ___________ of the ______________, a law fir! licensed to
practice law in ____________ and the Philippines, with address at
_________________"
#. $ur law fir! is the retained counsel of ______________, petitioner Case
%o. _________ &Petition for 'doption) , filed with the (eneral Court of )ustice,
*istrict Court in the State of %orth Carolina, with address at #+, %orth-iew *ri-e, San
.ord, %C #/00#"
0. I caused the publication of the ad-ertise!ent1notice described in the
attached official letterhead"
2. 's retained counsel of the petitioner &___________), I ha-e been
authori3ed by our law fir! to cause the publication of the said ad-ertise!ent1notice
and that the contents of the said ad-ertise!ent1notice are true and correct"
,. I affir! and warrant, on behalf of ________________, that &a) the
ad-ertise!ent1notice is &a) in accordance with law and go-ern!ent rules and
regulations" &b) does not and will not -iolate any order, resolution or decision of any
court or go-ern!ent office" and &c) is published in good faith and with 4ustifiable
!oti-es"
+. In !y personal capacity ad as the duly5authori3ed representati-e of the
law fir! and ______________ shall hold the Philippine *aily In6uirer free and
har!less fro! any co!plaint or clai! that !ay be filed against it, and be solidarily
liable for any da!ages that it !ay be ordered to pay, on account of or as a
conse6uence of the publication of the ad-ertise!ent1notice, without pre4udice to
whate-er action it !ay ta7e against !e and _____________ under the pre!ises.
Manila, Philippines, )anuary , #8#.
_________________
S9:SCRI:;* '%* S<$R% to before !e this
th
day of )anuary #8#, affiant
e=hibiting to !e her co!petent proof of identity, Social Security Syste! I* Card %o.
____________.
*oc. %o. ______"
Page %o. ______"
:oo7 %o. ______"
Series of #8#.