SWORN STATEMENT/SINUMPAANG SALAYSAY

I, _________________________________, Filipino, single/married, of legal age and

presently residing in _____________________________________________, working at
_________________________________, as _____________________________, after
having duly sworn in accordance with law, do hereby depose and state:

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IN WITNESS WHEREOF, I have hereunto set my hand this ____________________, at the

_________________________________.

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Signature over printed Name

SUBSCRIBED AND SWORN to before me this _______________, at the

_______________________.

Service No. ____________

Doc. No. ______________
Book No. ______________
Fee Paid ______________
O.R No. ______________