REPUBLIC OF THE PHILIPPINES )

CITY OF CAGAYAN DE ORO ) s.s.

SWORN DECLARATION OF INTENTION TO DEPART FROM THE

PHILIPPINES PERMANENTLY

I, __________ JR., of legal age, Filipino, married and with residence at

Block 9, Lot 6, Youngsville Subdivision, Igpit, Opol, Misamis Oriental after being
duly sworn in accordance with law, hereby deposes and states:

1. That I am a member of the Home Development Mutual Fund (Pag-IBIG

Fund), with Pag-IBIG MID No. ___________;

2. That I recently resigned from Philippine Sinter Corporation located at

Phividec Industrial Estate-Economic Zone, Villanueva, Misamis Oriental;

3. That I am a holder of Passport No. ___________ issued by DFA

Cagayan de Oro City;

4. An immigrant's visa has been issued to me by the Embassy of Ireland;

5. I am migrating to Ireland and will stay there permanently, being an

immigrant citizen thereof;

6. I am leaving the country within sixty (60) days from date hereof;

7. In the event that my permanent departure from the Philippines shall not
materialize for any reason whatsoever, I hereby agree to return or refund the
amounts paid to me by the Fund on account of my approved application for
provident benefits; and

8. I am executing this Affidavit to attest to the truth of my intention to

depart from the country permanently and to claim my provident benefits from the
Fund and for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my hand, this 28th of

December 2019 at the City of Cagayan de Oro.

JR.
PRC ID No. [Reg No.] 0009791
Valid until 05 August 2022
Issued in Cagayan de Oro City

SUBSCRIBED AND SWORN to before me this 28th of December 2019,

affiant exhibiting to me his evidence of identity above-mentioned.

Doc. No. 231;

Page No. 47;
Book No. VII;
Series of 2019.