REPUBLIC OF THE PHILIPPINES)

) S.S.

AFFIDAVIT OF NON FILING

I, , of legal age, single/married, Filipino, and a

resident of after having been
duly sworn to in accordance with the law, hereby depose and say:

1. I do not have sufficient source of income/unemployed for ;

2. That as a consequence I did not file my Income Tax Return for the past years;

3. That I am executing this affidavit, to attest to the truthfulness of the foregoing facts and for all legal
intents and purposes.

IN WITNESS WHEREOF, I have hereunto set my hands this day of , 20 at

.

Affiant

CTC No.

Issued at

SUBSCRIBED AND SWORN to before me this day of , 20 at

, affiant exhibited to me her Community Tax Certificate as indicated
above.

Doc. No.

; Page. No. ;

Book No. ;

Series of ;