REPUBLIC OF THE PHILIPPINES

CITY OF BATANGAS ) S.S.

AFFIDAVIT OF CITIZENSHIP
FOR BATAS PAMBANSA BLG. 185

I, ___________________________________, citizen of United States of America,

married, of legal age, and currently residing at _____________________________, after being
duly sworn to in accordance with law, depose and state THAT:

1. I was a natural-born Filipino Citizen, born in Lipa City, Batangas on September 10, 1967
to Filipino parents, namely: ________________________________
Attached hereto as Annex “A” is a copy of Certificate of Live Birth.

2. I am married to _____________________, of legal age, and currently residing at

______________________________

3. I have three children namely: ___________________________________________

4. I have lost my Filipino Citizenship through naturalization on June 8, 2005 and since then,
I have been a citizen of United States of America;

5. I am acquiring through purchase a parcel of land located in

G___________________________________________ with an area of 360 square
meters. I hereby affirm that this purchase combined with all of my land holdings in the
Philippines do not exceed 1,000 square meters aggregate;

6. I intend to use the aforementioned land to permanently reside in the Philippines;

7. That I am executing this Affidavit in compliance with Batas Pambansa Bilang 185 and
its implementing Rules and Regulations.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ day of ___________
2023 at Batangas City, Philippines.

__________________________________
Afffiant

SUBCRIBED AND SWORN TO before me this ___ day of _______________ 2023 at

Batangas City, affiant exhibiting to me her _________________________________

Doc. No. _____;

Page No. ____;
Book No. ____;
Series of 2023.