Republic of the Philippines)

City of Manila ) S.S.

AFFIDAVIT

I, _____________________________________________, of legal age, Filipino, assigned at

_____________________________________________, after having been sworn in accordance with
law hereby declare that:

1. I am an active member of the Philippine Coast Guard (PCG) with ___________ years of
Coast Guard Service;

2. I am a bona fide member of the PCGSLAI with corresponding Deposit Accounts such as
Capital Contribution, Special Savings Deposit and others;

3. I have applied for a ____________________________ (Type of Loan) with the Philippine

Coast Guard Savings and Loan Association, Inc. (PCGSLAI);

4. I hereby bind myself to pay the PCGSLAI my outstanding loan obligation relative to the
execution of this Affidavit;

5. I hereby authorize the PCGSLAI to deduct the loan amount from my Deposit Accounts in
the event of a default in my monthly payment;

6. I further authorize the PCGSLAI to collect from the Coast Guard Finance Center (CGFC)
my leave credit receivables in the event of separation from the PCG either by resignation,
dismissal, honorably or otherwise, or will be Absent Without Leave (AWOL).

7. That I am executing this Affidavit to attest and affirm to the truthfulness and veracity of
the foregoing facts that may be used for whatever legal purpose it may serve.

Signed at ______________________________________ on ____________________________.

____________________________
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, this ___________ day of ______________ in the
City of ____________________, Philippines, Affiant exhibiting to me his/her Government ID
__________ No. _______ valid until ___________________.

NOTARY PUBLIC

Doc No. ________

Page No. ________
Book No. _______
Series _________;