REPUBLIC OF THE PHILIPPINES )

CITY OF DAPITAN ) S.S.

AFFIDAVIT OF CITIZENSHIP

I, (Name of the Affiant), of legal age, Filipino, single and a resident of

(Affiant’s Complete resident address, after having been duly sworn to in
accordance with law, depose and state:

1. I am a Filipino Citizen from birth until the present.

2. On (Date of Birth), my son (Name of the child) was born in Brussels,

Belguium.

3. (Name of the child) is also a Filipino Citizen pursuant to the provisions

of the 1987 Philippine Constitution.

4. At the time of birth of (Name of the child), both his parents, were, and
still is, Filipino Citizens.

5. I therefore have executed this Affidavit to attest to the truth I mentioned

herein and for whatever legal purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this (nth) day

of (month, year) in Dapitan City, Zamboanga Del Norte, Philippines.

(Name of the Affiant)

Affiant
With Philippine Passport No. (xxxxx)

SUBCRIBED AND SWORN TO before me this (nth) day of (month,

year) in Dapitan City, Zamboanga Del Norte, Philippines, affiant exhibiting
to me her Philippine Passport No. (xxxxxx) issued in Manila on (Date issued)
and valid until (Expiry Date).

Doc. No. (xxxxxx);

Page No. (xxxxxx);
Book No. (xxxxxx);
Series of 2022.

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