REPUBLIC OF THE PHILIPPINES)

PROVINCE OF ANTIQUE ) S.S.

MUNICIPALITY OF SAN JOSE )
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AFFIDAVIT OF NO EXISTING SCHOLARSHIP GRANTS

I, ___________________, _____ years old, single, Filipino and a resident

of Barangay ________________.________________, Antique, after having
been duly sworn to in accordance with law, do hereby depose and state, that:

1. I am currently a ______________ student of

_______________________;

2. I wanted to pursue my college/ tertiary education at

______________________________________and avail of the
scholarship grant from the ______________________________;

3. I am currently not a recipient of any scholarship grants from any

government or private institutions. I am also not an applicant of any
scholarship programs of any institution except for an application with
the ________________________________; and

4. I am executing this Affidavit to attest to the truth of the foregoing

facts and for any legal purpose that this Affidavit of No Existing
Scholarship Grants may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this

_________________________ at San Jose, Antique

_______________________
Affiant

SUBSCRIBED AND SWORN to before me this__________________,

at San Jose, Antique. Affiant exhibiting to me his/ her valid identification
indicated below his/her name.