REPUBLIC OF THE PHILIPPINES)

CITY OF _______________________) SS.

AFFIDAVIT

I,________________________________________________, of legal age, Filipino,

single/married/widow/er and presently residing at
______________________________________________________________, after being
duly sworn to in accordance with law, depose and state that:

1. I personally know ____, resident of ___ City;

2. I declare, confirm and affirm that ____ is an ____, who is the ____ of
___ located at _____ City;

3. I likewise declare, confirm, and affirm that ____ can usually, _____;

4. I am executing this affidavit to confirm and affirm the foregoing facts

and for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hands this ____ day of _______, 20__ at
_________________. Affiant exhibiting his/her __________________, government issued ID, issued
on _______________ at ________________ which will be expired on __________________.

NOTARY PUBLIC

Doc. No. ____________;

Page No. ____________;
Book No. ____________;
Series of ____________.