MLP-01271 (04-2016)
REPUBLIC OF THE PHILIPPINES)
PROVINCE OF ) 8s.
AFFIDAVIT OF RESIDENCY
Filipino, of legal age, singlefmarried, with
residence address at
after having been duly sworn fo in accordance with law, do hereby depose and state, that
WITNESS my hand this at
3S
1
2
5.
SUBSCRIBED AND SWORN to before me this
| am a bonafide member of the Secial Security System with SS No.
My address (work/home) was at
with postal code when (name of
calamity/disaster) happened,
My capacity to pay my loan/s with SSS has been impaired by the calamity/disaster
that occurred in the aforesaid adcress which resuited to incurrence of interests and
penalties of the said loanis:
| understand that in case it is proven that | have given false information or
misrepresentation in this document or in any other documents submitted in
connection with my Loan Restructuring Application, | undertake to pay the
outstanding balance of the loan including the condoned penalty;
| am executing this Affidavit to attest to the truthfullness of the foregoing statements.
at
affiant exhibiting hisihe
1D No. or Community Tax No issued on
at
‘Administering Officer, Foreign Office