AFFIDAVITS OR SWORN STATEMENTS

Republic of the Philippines)

City of Manila ) S.S.

AFFIRMATION

BEFORE ME, this 5th day of June 2-16 in the City of Manila, personally appeared Juan
Dela Cruz, and presented to me his [Valid Identification Document] issued by the [Official
Agency] on [Date of Issuance] and who avowed under penalty of law to the whole truth of the
contents of the instrument or document he presented to me.

WITNESS MY HAND AND SEAL, at the place and on the date first above written.

ATTY. JUAN DELA CRUZ

Notary Public for Manila
Unit I, X Building, Recto, Manila
Appointment No, 123, Until December 31, 2017
IBP No. 123456; 01/10/15- Manila
PTR No. 1234567; 01/10/15- Manila
Roll No. 12345; 4/20/06
MCLE No. I- 001234; 9/09/14
MCLE No. II- 005678; 9/09/14
Serial No. of Commission M- 123

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2016.