REPUBLIC OF THE PHILIPPINES)

_____________________ ) SS.

AFFIDAVIT

I, ________________________, of legal age, ____________, and with address at ___________________________, under oath, state:

  1. THAT I __________________________;
  2. xxxxxx
  3. xxxxxx

4. THAT I am executing this Affidavit to attest to the truth of the foregoing facts and to use the same for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I hereunto affix my signature this _________________ at ________________________.

_____________________

Affiant

SUBSCRIBED AND SWORN to before me this _______________ at _______________, Affiant exhibiting to me his/her Comm. Tax Cert. _____________ issued at ______________ on _________________.

Doc No. ________;

Page No. _______ ;

Book No. _______;

Series of ________.