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REPUBLIC OF THE PHILIPPINES)

____________, METRO MANILA ) S.S.

IN WITNESS WHEREOF, I have hereunto


_______________ in ______ City, Metro Manila.

set

my

hand

this

NAME
Affiant
SUBSCRIBED AND SWORN TO before me this _______________ at
_____ City, affiant exhibiting to me his _________________ issued in
________________ valid until _______________.
Doc. No. ______;
Page No. ______;
Book No. ______;
Series of 2016.

SUBSCRIBED AND SWORN to before me this ___________ at


____________________ City, Metro Manila, affiant exhibiting to me
_________________________ issued by _______________________ on/valid until
________________________.
Doc. No. ____;
Page No. ____;
Book No. ____;
Series of 2016.

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