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Republic of the Philippines )

City of _______________ ) S.s.

AFFIDAVIT

I, ____________, of legal age, single and with residence and postal


address at _____________, after having been duly sworn in accordance with law
do hereby depose and state that:

1. I was born on ____________ in ____________________ of


parents ______ and _______;

2. My parents are natural-born Filipino citizens, both being citizens of


the Philippines from birth without having to perform any act to
acquire or perfect their Philippine citizenship.

3. As I was born in ________, I am also a citizen of ________.

4. This being the case, I possess dual citizenship. Thus, I am a


Filipino citizen and at the same time a ________.

5. I am executing this Affidavit to attest to the truth of the foregoing


and for whatever purpose it may serve..

IN WITNESS WHEREOF, I have hereunto set my hand this ______ of


December 2004.

_____________________
Affiant

SUBSCRIBED AND SWORN, before me this ___day of


__________________ Affiant, affiant exhibiting to me his Community Tax
Certificate Receipt No. ____________________ issued at _________________
on _____________________.

Notary Public

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