REPUBLIC OF THE PHILIPPINES)

___________________________ ) S.S.

AFFIDAVIT OF CITIZENSHIP
I, ______________________________, citizen of the United States of America, of legal
age with residence and postal address at ______________________________________, after
having been sworn in accordance with law, hereby depose and state that:

1. I was a natural-born Filipino citizen, born in __________________________________ on

____________________ to Filipino parents, namely: __________________ and
__________________ who are alive and now residing at
____________________________________________________;

2. I am married to __________________________________, of legal age with residence and

postal address at ____________________________________________:

3. I have one child named ________________________________;

4. I have lost my Filipino citizenship through naturalization on _____________________ and

since then I have been a citizen of the United States of America;

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

_____________________________________ with an area of
_________________________ square meters. I hereby affirm that this purchase combined
with all of my other 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 on my

retirement; and

7. I am executing this sworn statement in compliance with Land Registrtion Authority, Registry
of Deeds for the City of Batangas.

WITNESS WHEREOF, I have hereunto set our hand this _________________ day of at
____________________________________.

Affiant

SUBSCRIBED AND SWORN to before me, a Notary Public for and in the
_________________________________, this ____ day of _________________, 2021 affiants
exhibited to me her __________________________.

Doc. No. _____

Page No._____
Book No._____
Series of 2021

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