Republic of the Philippines )

Province of Pangasinan ) Sc.

Municipality of Villasis )

AFFIDAVIT OF LOW INCOME

I, LOURDES M. BURGOS, of legal age, married, Filipino citizen and a

resident of Brgy. Lipay, Villasis, Pangasinan, after having been duly sworn to an
oath in accordance with law, hereby depose and states that:

1. That I am the guardian of “DANICA A. REYES” who is presently

applying for PROVINCIAL SCHOLARSHIP PROGRAM (PSP);

2. That I am a plain housewife and my husband is a mere tricycle driver;

3. That I and my husband are the registered owner of an agricultural lot

with an area of 1,000 sq. meters;

4. That I and my husband do not file income tax return before the
Bureau of Internal Revenue (BIR) for the reason that we fall under the
category of those who are exempted to file the same; and

5. I am executing this affidavit to attest to the truth of the foregoing

statements and for all legal intents and purposes this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 11 th day of

April 2018 at Villasis, Pangsinan.

LOURDES M. BURGOS
Affiant
Sr. Citizen ID Card No.4358

SUBSCRIBED AND SWORN to before me on the date and place above

written. Affiant personally appeared and declared under oath that she voluntarily
execute, read and understood her statement to be true based on her personal
Knowledge;

jea