REPUBLIC OF THE PHILIPPINES)

Province of ______ ) S.S.

City of _______ )
x------------------------x

AFFIDAVIT
I, ___________, of legal age, Filipino, married and with residence address at
___________, after being duly sworn in accordance with law, depose and state:
1. That I am an employees of the _______;
2. That one of my assigned jobs is to receive checks from the outlets and to issue
corresponding Collection Receipt to the customer;
3. That on _________, I received a check from _________;
4. As such, I am executing this affidavit to attest to the truth of the foregoing facts.

IN WITNESS WHEREOF, I have hereunto set my hand this ____________ at _________

____________________
AFFIANT
ID NO: __________________

SUBSCRIBED AND SWORN to before me, this ___________ at ______________