REPUBLIC OF THE PHILPPINES)

_____________________ CITY ) S.S.

AFFIDAVIT

I, ___________, _________________, of legal age, with address at _______________________________,

after being duly sworn in accordance with law, hereby depose and state that:

1. xxx

2. xxx

2.1. xxx

2.2. xxx

2.3. xxx

3. I am executing this affidavit to the truth of the foregoing.

IN WITNESS WHEREOF, I have set my hand this _______________________ at ______________

City.

_______________________
Affiant

SUBSCRIBED AND SWORN to before me, this _________________ at __________ City, the
affiant appearing before me and showing, as competent proof of his/her identity, his/her
____________________ No. _____________, issued on _____________ at ____________________.

Doc. No. _____;

Page. No. _____;
Book. No. _____;
Series of 2014.