Republic of the Philippines )

City of Cebu )S.S

AFFIDAVIT

I, _________________, _____________national, of legal age, married and with

residence address at__________________________, after having been duly sworn to in
accordance with law depose and state:

That I am a holder of ____________valid until____________;

That in ____, I applied for Voluntary ACR-ICARD by reason of my Balikbayan Visa and
the Bureau of Immigration, Manila issued Voluntary_________________, dated May 3, 2016;

That however, I was not able to claim the aforementioned ACR-ICARD so I asked for its
cancellation and applied for a new one with the Bureau of Immigration;

That I am executing this affidavit for the purpose of securing a new Voluntary ACR-
ICARD from the Bureau of Immigration;

That further Affiant sayeth naught.

DONE and SIGNED this______ day of August 2019 at________________, Philippines.

___________________I
AFFIANT

SUBSCRIBED AND SWORN to before me, this _____ day of August 2019 at Cebu
City.

SIGNED and SEALED this ____ day of August 2019 at Cebu City Philippines.

NOTARY PUBLIC

Doc. No. _____

Page No. _____
Book No. _____
Series of 2019