Republic of the Philippines)

Province of Aklan )S.S.

Municipality of Altavas )
x-x-x-x-x-x-x-x-x-x-x-x-x-x

AFFIDAVIT

That I, ___________________________________, ___, years of age, single/married

Filipino citizen and a resident of _____________________, Altavas, Aklan, Philippines, and after
having been duly sworn to in accordance with law, de hereby depose and state;

That I am the mother/father of _______________________________________, who was

born on ________________________________ at _______________________, Altavas, Aklan,
Philippines;

That he/she is my illegitimate son/daughter;

The he/she is my _______________ child;

That _________________________________ of ___________________Altavas, Aklan,

was the ____________________________________ who assisted the delivery of my said child.

Further, Affiants sayeth none.

IN TRUTH OF THE FOREGOING, I hereunto affixed my signature this _______ day of

____________________ 2017 at Altavas, Aklan, Philippines.

______________________________
(Affiant)

Comm. Tax No. ________________

Issued at ______________________
On___________________________

SUBSCRIBED AND SWORN to before me this _____ day of _____________________

2017 at Altavas, Aklan, Philippines. Affiant exhibited to me his/her Community Tax Number
below his/her signature.

DENNY D. REFOL
Municipal Mayor