REPUBLIC OF THE PHILIPPINES)

) S.S.

SWORN STATEMENT

I, ________________, of legal age, Filipino, with residential address at

______________________________________________________________, after
being duly sworn to, hereby depose and say that:

1. I am a _______________ at ________________________.

2. I was the _______________________ on

___________________________.

3. As ______________, it is part of my duties and responsibilities to

_____________________________________.

4. During my shift, _______________________________.

5. At around ________________ of _________________, I was tasked to

__________________________________________.

6. I reported the foregoing incidents to the _________________________.

7. I am executing this Affidavit to attest to the truth of the foregoing and for
any and all legal intents and purposes.

IN WITNESS WHEREOF, I have hereunto set my hand this

___________________ at ___________________.

________________
Affiant

SUBSCRIBED AND SWORN to before me at ___________ this

__________________. I hereby certify that I have personally examined the affiant and
that I am satisfied that the affiant voluntarily executed this Sworn Statement and that
she understood the contents thereof.
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of ______.