DECLARATION OF INTENTION TO BECOME A FILIPINO CITIZEN

DECLARATION OF INTENTION

_________________________, do declare on oath that:

1. It is my intention in good faith to become a citizen of the Philippines and to

permanently reside therein;

2. My full name is ____________________ (alias or otherwise known as [if any])

3. I am ___ years old, and my occupation is _____________;

4. I am single/married;

5. My wife’s name is ____________ who was bom ____________ On

___________, and now resides at ___________________;

6. I have children and the name, date and place of birth, and place of residence of
each of said children are as follows: _________;

7. My personal description is: racial color________________;

complexion,________; height,_______; weight,_______; color of hair __________; color of
eyes__________; other :_____________.

8. Two photographs of myself are hereto attached, duly signed and autographed by
me;

9. I was bom in _______________ on _______________;

10. I now reside at ______________________________;

11. My last foreign residence was _____________________;

12. I emigrated to the Philippines from ___________________, thru (state

circumstances of arrival), as shown by the certificate of my arrival issued by the Bureau of
Immigration, hereto attached and which shows my lawful entry for permanent residence.

13. I will, upon being admitted to Philippine citizenship, renounce forever all
allegiance and fidelity to any foreign prince, potentate, state or sovereignty, and particularly to
_______________, of which at this time I am a citizen/subject;

14. I am not an anarchist; I am not a polygamist nor a believer in the practice of

polygamy; I have not been convicted of any crime involving moral turpitude; I am not suffering
from any incurable disease. I have mingled socially with Filipinos and I have learned to love and
embrace the customs, traditions, and ideals of the Filipinos;

15. I have enrolled my children during my entire period of residence in the

Philippines, in the following schools, where Philippine history, government, and civics are taught
or prescribed as part of the school curriculum;

16. I believe in the principles underlying the Philippine Constitution.

So help me God.

(Affiant’s signature)

JURAT