I, ____________, of legal age, single and with residence and postal
address at _____________, after having been duly sworn in accordance with law do hereby depose and state that:
1. I was born on ____________ in ____________________ of
parents ______ and _______;
2. My parents are natural-born Filipino citizens, both being citizens of
the Philippines from birth without having to perform any act to acquire or perfect their Philippine citizenship.
3. As I was born in ________, I am also a citizen of ________.
4. This being the case, I possess dual citizenship. Thus, I am a
Filipino citizen and at the same time a ________.
5. I am executing this Affidavit to attest to the truth of the foregoing
and for whatever purpose it may serve..
IN WITNESS WHEREOF, I have hereunto set my hand this ______ of
December 2004.
_____________________ Affiant
SUBSCRIBED AND SWORN, before me this ___day of
__________________ Affiant, affiant exhibiting to me his Community Tax Certificate Receipt No. ____________________ issued at _________________ on _____________________.