REPUBLIC OF THE PHILIPPINES )

Makati City              ) SS.

AFFIDAVIT

I, JUAN DELA CRUZ, of legal age, single and with address at

xxxxxxxxxxxxx, under oath, state:

1. THAT I __________________________;

xxxxxx
xxxxxx

4.   THAT I am executing this Affidavit to attest to the truth of

the foregoing facts and to use the same for whatever
legal purpose it may serve.

IN WITNESS WHEREOF, I hereunto affix my signature this xx

March 2016 at Makati City.

_____________________
Affiant

SUBSCRIBED AND SWORN TO before me, this _______________,

Affiant exhibiting to me his/her competent evidence of
identity bearing his/her picture and signature as described
below:

NAME TYPE OF NUMBER DATE AND PLACE

ID. OF
ISSUANCE/EXPIRY
DATE.

JUAN PASSPORT A34567 ISSUED ON 3/5/16

DELA AND EXPIRING ON
CRUZ 3/5/21.

WITNESS MY HAND AND SEAL at the place and on the date

first-above written.

Doc. No. _______;

Page No. _______;
Book No. ______;
Series of _______.