Republic of the Philippines)

Quezon City ) S.S.

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AFFIDAVIT

I, FO1 Jayson E. Rivera, Filipino, of legal age, single, and a resident of Tilasan RT Lim, Zamboanga
Sibugay, Philippines, after being sworn to in accordance with law, depose and state:

1. That I am a bonafide member of Bureau of Fire Protection, presently assigned at Galas Fire Sub-
station, Quezon City, FD-V as Engine Crew;

2. That my signature might have changed/ altered by passing of time and therefore I request the Bureau to
treat my signature as per the records maintained with the Bureau of Fire Protection as cancelled;

3. That the specimen signature given below be taken as cancelled:

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4. That my specimen signature below be taken on record:

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5. That I am executing this Affidavit to attest to the truth of the foregoing and for whatever legal purpose
it may serve.

IN WITNESS HEREOF, I have hereunto affixed my signature this ______________ in ______________,

Philippines.

FO1 Jayson E. Rivera

Affiant

SUBSCRIBED AND SWORN to before me this _____________in ______________,

Philippines, affiant exhibited his PSSLAI ID with number 323179 issued at PSSLAI main office.

NOTARY