REPUBLIC OF THE PHILIPPINES)

________ CITY
) SS.

AFFIDAVIT
I, ________________, Filipino, of legal age, with address at
__________________________________, after having been sworn to in accordance with law
hereby depose and state that:
1. ]
2. ]

STATE THE FACTS!

3.]
4. I herein attest to the truthfulness of the foregoing facts.
AFFIANT FURTHER SAYETH NAUGHT.
IN WITNESS WHEREOF, I hereby affix my signature this ___ day of __________200__ in
___________ City.

_______________________
Affiant
SUBSCRIBED AND SWORN to before me, a Notary Public, this ___ day of ____________
200__ at _____________ City, affiant exhibited to me his Community Tax Certificate No.
____________ issued on ______________ at ______________.