Republic of the Philippines ) S.S.

Dagupan City )

I, , of legal age, resident of , having been duly sworn in accordance with law, hereby, depose and say:
1. That
2.
That I am executing this affidavit to <brief purpose, to correct etc.> and attest to the truth of the
foregoing statements.

I, hereby, voluntarily sign below to uphold the truth of my statements.

IN WITNESS WHEREOF, I have hereunto affixed my signature this _____ day of ___________
2017, in Dagupan City, Philippines.

Affiant

SIGNED IN THE PRESENCE OF

______________________________ ______________________________

SUBSCRIBED AND SWORN TO before me this ______ day of __________ 2017, by, who exhibited to
me her ID_______________________.

Notary Public

Doc. No. .........:

Page No. .........;
Book No. .........;
Series of 2017.