Republic of the Philippines )

Province of Pangasinan )
Municipality of Malasiqui ) S.S.

AFFIDAVIT

I, _____________________________, of legal age, single, Filipino

citizen, and presently residing in _____________________, San Carlos
City, Pangasinan, after having been sworn to in accordance with law,
do hereby depose and state that:

1. I am presently residing in our family house located in Brgy.

_________________, San Carlos City, Pangasinan.

2. Our family house at the above-mentioned address has no

house number.

3. In view of the above reason, it is not possible for me to provide

a house number as required in my Sworn Statement of Assets,
Liabilities and Net Worth.

4. I am executing this affidavit to attest to the truth of the

foregoing and for whatever legal purpose it may serve.

AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto set my hand this 24th

day of January 2017 at Malasiqui, Pangasinan.

_____________________________________________
Affiant
PRC _________________________
Valid until 03-06-2017

SUBSCRIBED AND SWORN TO before me on the date and at the

place first above mentioned, affiant exhibiting to me his competent
evidence of identity already appearing below his name and signature.

Doc. No. ____;

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