REPUBLIC OF THE PHILIPPINES )

PHILIPPINE CONSULATE GENERAL ) S.S.

LOS ANGELES, CALIFORNIA, U.S.A. )

AFFIDAVIT OF UNDERTAKING
I, ______________________________, ___________ citizen, of legal age and presently residing
at COMPLETE ADDRESS IN USA
___________________________________________________________________________________
after having been duly sworn in accordance with the law, hereby depose and state that:
STATE SPECIFIC AGENCY/AGENCIES
I am submitting these documents from ______________________________________________
as part of the requirements in the Philippines for _____________________________________________
___________________________________________________________, to wit:

1. ________________________________________________________________;
2. ________________________________________________________________;
3. ________________________________________________________________;
4. ________________________________________________________________;
5. ________________________________________________________________;
6. ________________________________________________________________;
7. ________________________________________________________________;
8. ________________________________________________________________;
9. ________________________________________________________________;
10. _______________________________________________________________;

Affiant further sayeth naught.

MONTH
IN WITNESS WHEREOF, I have hereunto affixed my signature this ____ day of _____________
PLACE
20___, in Los WERE
Angeles, YOU SIGNED
California, THIS AFFIDAVIT
U.S.A.

_______________________________
Printed Name and Signature of Affiant