Republic of the Philippines)

City of _______________ )S.S.

SWORN AFFIDAVIT

That I, __________________________, married, and of legal age, own and manage

_______________________________, a duly registered and licensed
_____________________________________, with office address located at ________

________________________________, and after being duly sworn to law, depose and say:

1. That the firm stated above has not been operating under a different name other than what
has been duly registered with the Department of Trade and Industry and duly licensed to operate in
_______________ by the City Mayor’s Office;

2. That the said firm has not been charged with any labor case in the Department of Labor and
Employment and in the National Labor and Reconciliation Commission, nor having pending cases with
the same;

3. That the said firm has not been operating with a Trade Name that has a cancelled registration
with the Department of Trade and Industry;

That I am further executing this affidavit to affirm the truth of my foregoing statements and for
whatever legal purpose it may serve me best.

IN WITNESS WHEREOF, affixed my signature this ___ day of _________ 2012 at

______________________________

_____________________

Affiant

SUBSCRIBED AND SWORN to before me this ____ day of ____________2012 affiant presented
to me his/her Community Tax Certificate # ________________ issued on ______________ issued at
_________________.

Known to me and known to be the same person who executed the foregoing affidavit.

Book No. __________

Doc. No.__________

Page No. _________

Series of 2012______