Republic of the Philippines}

s}
s}

AFFIDAVIT OF CONFIRMATION

I, JEROME VEÑALES ROXAS a Filipino, of legal age, a resident of

BRGY. LUMINGON, TIAONG, QUEZON a bonafide member of the Philippine National Police with rank
of PO1 and presently assigned at SAN ANTONIO MPS SAN ANTONIO, QUEZON after having
been duly sworn to in accordance with law, do hereby depose and say that;

1. Pursuant to this affidavit, I am confirming that the following are my legal beneficiaries and/or
heirs, to wit;

NAME RELATIONSHIP BIRTH DATE

ADRENNE ROBLES ROXAS WIFE FEBRUARY 3, 1991

ORIENA JERENE ROBLES ROXAS DAUGHTER MARCH 5, 2015
ALLEYAH JERENE ROBLES ROXAS DAUGHTER SEPTEMBER 25, 2017

2. My relationship with persons whose names are listed above are borne out by the fact that I am
the lawful spouse and the father/mother of the afore-named children as evidenced by the
attached advisory on marriages, marriage contract and birth certificates;

3. That all the documents I have attached and submitted to support the updating of my DLB are
original copies obtained from Philippine Statistics Authority; and

4. I hold myself criminally and administratively liable for perjury and dishonesty should any
statements made herein/documents submitted herewith are inaccurate or later found to be
false and in violation of law.

AFFIANT SAYETH NAUGHT:

_______________________________
Affiant
Contact No: _____________________

SUBSCRIBED AND SWORN to before me this ________ day of ______________ at

________________________, Philippines.

Doc No. _________

Page No. _________
Book No. _________
Series No. _________