STATUTORY DECLARATION

This declaration must be made before an authorised person. Only certain people may witness a
Commonwealth statutory declaration. A list of people who can be witnesses is set out in Schedule 2 to the
Statutory Declaration Regulations 2018. The Regulations and a separate 'list of signatories' can be accessed
via a link at https://www.legislation.gov.au.

WARNING: When you make a statutory declaration, you are declaring that the statements in it are true. If
you intentionally make a false statement in a statutory declaration, you could be charged with an offence
and, if convicted, you could be fined or jailed, or both.

The provision of false or misleading information in this declaration is subject to penalties under the
Statutory Declarations Act 1959 and the Migration Act 1958. The Statutory Declarations Act provides for
penalties of up to 4 years imprisonment. Section 234 of the Migration Act carries a penalty of up to 10
years imprisonment for knowingly making a false statement in connection with a visa application.
Republic of the Philippines
City of Dasmariñas, Cavite

SWORN STATEMENT

I, SALVADOR TANIEGRA CARRANZA, of legal age, widow, and a resident

of Block 02, Lot 46, Ville De Soleil, Brgy. Langkaan I, Dasmariñas City, Cavite,
4114, Philippines, do solemnly and sincerely declare that:

That I am an Overseas Filipino Worker and I worked as Auto Denter on May 23, 1992 to
August 4, 1994 in TOYOTA NAJRAN RIYADH, SAUDI ARABIA

I hereby certify that I answered the following question honestly and truthfully to the best of
my knowledge and belief.

1. List of all the period of residence in the country of question?

Answer: May 23,1992 to August 4,1994

2. Province addess details for each period of residence?

Answer: NAJARAN RIYADH SAUDI ARABIA

3. Advise all types of visa held and for what period of residence?

Answer: Type of Visa, Working.

Period of Visa: May 23, 1992 to August 4,1994

4. Have you ever held a resident permit for the country of question? If so, please list
passport numbers containing associated visas

Answer: Yes

New Passport: PO712671B

5. If employed within the country of question, were you sponsored by your employer?

Answer: Yes.

6. On resignation or departure from your employer, did you finalize your visa
obligations in association with your employer?

Answer: Yes
 I understand that any incorrect information may result in refusal of my application or, if a visa has been
granted, the cancellation of my visa. I understand that, if my visa is cancelled after entry to Australia, I will
be required to leave Australia.

SALVADOR TANIEGRA CARRANZA

Affiant

Declared at ____________________this______ day _____2 __

Before me, a Notary Public in the City of _______________, Cavite, Philippines, on the date and
place written above, the Affiant personally appeared before me whom I have identified through his competent
evidence of identity and who exhibited to me his Philippine Passport bearing No. P0712671B issued by the
Department of Foreign Affairs (DFA) in Manila, Philippines.

NOTARY PUBLIC

Doc. No. _______;

Page No. _______;
Book No. _______;
Series of 20____.