REPUBLIC OF THE PHILIPPINES )

PROVINCE OF _______________ ) SS
MUNICIPALITY OF ___________ )

We, __________________________, of legal age, Filipino single/married

to________________________ and resident of
#__________________________________________________, Philippines and
__________________________, of legal age, single/married, after having been duly
sworn to in accordance with law hereby depose and say:

1. That we _____________;

2. That we _____________;

That we are executing this affidavit to attest to the truth of the foregoing
circumstances and for the purpose of informing the authorities/office concerned so that
the above-said discrepancy can be corrected accordingly or as required by law or
jurisprudence.

IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of

________________________ Quezon City, Metro Manila, Philippines.

____________________
Affiant

SUBSCRIBED AND SWORN to before me this ______ day of

__________________ in __________, Affiant exhibited to me their Community Tax
Certificate No. _____________ issued at ____________________ on
___________________.

Doc. No. : _____;

Page No. : _____;
Book No.: _____;
Series of _____;