REPUBLIC OF THE PHILIPPINES )

PROVINCE OF ALBAY )
CITY/MUNICIPALITY OF ________________)

AFFIDAVIT

I, ______________________________, of legal age, Filipino and a resident of

_____________________________, after being sworn to in accordance with law,
hereby depose and say, that:
Freshmen:

I, will be enrolling at ___________________________________, to be

enrolled for School Year - _________________;

Old Student:

I, am a student of __________________________________, enrolled for

School Year - _____________;

I am not a recipient nor have I applied for any scholarship grant or any
Nationally Funded Financial Assistance Program, and violation of such shall mean
automatic forfeiture of the assistance and disqualification of my application for the
Office of the Vice Governor-Province of Albay G.R.E.X. Educational Assistance Grant.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ______ day

of ___________,____________ at __________________ City, Philippines.

________________________________
NAME AND SIGNATURE OF APPLICANT
Affiant

SUBSCRIBED AND SWORN to before me this ___ of __________ at ___________ City,

Philippines, after affiant exhibiting to me his Community Tax Certificate No.______
issued on ___________ at ________________.

Doc. No. ________: Notary Public

Page No. ________:
Book No.________:
Series of 2022