REPUBLIC OF THE PHILIPPINES )

MUNICIPALITY OF BALIUAG ) S.S.

PROVINCE OF BULACAN )

AFFIDAVIT OF NO INCOME

I, _____________________, of legal age, Filipino citizen, single, with

residence and postal address at
___________________________________________ , after having been duly
sworn in accordance with law, hereby depose and state:

1. That I am a student of ___________________ with student number

___________________;

2. That I am currently applying in a Scholarship Program under the Ched Student

Financial Assistance Program;

3. That one of the requirements is a proof of the Bureau of Internal Revenue (BIR)
validated Income Tax Return (ITR) of parents/guardian.

4. That the occupation of my mother, NAME OF MOTHER, is a/an

_________________;

5. That my parent did not file an Income Tax Return (ITR) at the BIR because my
mothers income does not exceed Php 60,000.00;

6. That I am executing this affidavit to attest to the truth of all the above facts and
statement for all legal intents and purposes it may serve.

___________________________
Affiant
IN WITNESS WHEREOF, I have hereunto set my hand this 22nd day of
August 2017 at Baliuag, Bulacan, Philippines.

SUBSCRIBED AND SWORN TO BEFORE ME, a notary public in and

for Baliuag, Bulacan this 22nd day of August 2017. Affiant personally came and
appeared with his/her ___________________________ I.D. with I.D. No.
______________________ who exhibited to me as his/her competent evidence of
identity.

DOC. NO. ____;

PAGE NO. ____;
BOOK NO. ____;
SERIES OF 2017