Republic of the Philippines )

Quezon City ) s. s.

AFFIDAVIT

I, ____________________, of legal age, Filipino, resident of _________________, and with

assistance of counsel, do hereby state under oath that:

1.
2.

3.

4.

5.

6.

TO THE TRUTH OF THE FOREGOING, I have signed this Affidavit on ____________ (date).

(Sgd.)
Name of Affiant

SUBSCRIBED AND SWORN TO before me in the City of ___________________ on this day of

___________________, affiant exhibiting before me his/her ________________ issued on
____________________ at __________________________.

Atty. _______________________________
Notary Public for __(place commissioned)__
Commission Serial No. _________________
Until (date)
(Office Address)
Roll of Attorney No.
PTR No. ____ / issued at _____ / on _______
IBP No. ____ / issued at _____ / on ________

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Series of 2013.