Republic of the Philippines )

City of Cebu ) s.s.

SELF- AFFIDAVIT

I, ________________, a Filipino, of legal age and is presently residing at

Kangkaibe, Bantayan, Cebu, after having been jointly sworn to in accordance with law
do hereby depose and state: - That

1. I was previously employed with ____________ for the period __________;

2. _____________ made remittances to PAG-IBIG using the name

________________ but it should have been for my correct name of
_____________;

3. I am required by PAG-IBIG Fund office to secure any certification from the

said employers, but such document could not be obtained since the company
has change is employees and its company name to SUPERSTAR and its
record is no longer available;

4. That the name ____________ previously employed with ____________

and the name ____________ refer to one and the same person, and the
name ____________ should be the one to be retained in the file;

5. I am executing this affidavit to attest to the truthfulness of all the foregoing

facts and for whatever legal purposes it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signatures this 9 th day of

____________ at ____________, Philippines.

____________
Affiant
ID No____________

SUBSCRIBED AND SWORN to before me this ____________ at ____________,

Philippines. Further certify that I personally examined the affiant and that I am satisfied
that he understand his statement.

NOTARY PUBLIC