REPUBLIC OF THE PHILIPPINES)________ CITY ) SS.

AFFIDAVITI, ________________, Filipino, of legal age, with address at __________________________________, after having been sworn to in accordance with law hereby depose and state that:1. ]

2. ] STATE THE FACTS!

3.]

4. I herein attest to the truthfulness of the foregoing facts.

AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, I hereby affix my signature this ___ day of __________200__ in ___________ City.

_______________________ Affiant

SUBSCRIBED AND SWORN to before me, a Notary Public, this ___ day of ____________ 200__ at _____________ City, affiant exhibited to me his Community Tax Certificate No. ____________ issued on ______________ at ______________.