Republic of the Philippines )

City of Malolos, Bulacan ) S.S.

SWORN CERTIFICATION
(with House Location Sketch)

I, (NAME NG BARANGAY CHAIRMAN), of legal age, Filipino

Citizen, and a resident of Barangay Lugam, City of Malolos,
Bulacan, after having been duly sworn to in accordance with law do
hereby voluntarily depose and say:

1. THAT, I am the Barangay Chairman (sample lang) of

Barangay Lugam, City of Malolos, Bulacan;

2. THAT, I verify that the present address of the petitioner is

at 888, Lugam, City of Malolos, Bulacan;

3. THAT, the petitioner has been residing thereat for at least

SIX (6) months prior to (date kung kelan finile ung
petition), the date of filing of the petition;

4. THAT, attached herewith is the certified copy of the House

of Location Sketch as ANNEX “A”;

5. THAT, I am executing the instant Sworn Certification in

order to attest to the truth of the foregoing and for whatever
legal intent and purposes it may serve.

________________________
Affiant

SUBSCRIBED AND SWORN to before me this _____ day of

September, 2019 here at City of Malolos, Bulacan. Affiant exhibited
to me his valid identification card with number
___________________________ bearing his photograph and signature

NOTARY PUBLIC
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 2019.