REPUBLIC OF THE PHILIPPINES ) ) S.S.

AFFIDAVIT

I, ______, American Citizens, of legal age with residence and postal address at ______, after having been sworn in accordance with law, hereby depose and state that:

1. I was a natural-born Filipino Citizen, born in ______on ______to Filipino parents, namely: ______and ______who are now residing at ______.

2. I have lost my Filipino Citizenship through naturalization on ______and since then I have been a citizen of the United States of America.

3. I am acquiring through purchase a parcel of land located in ______with an area of _____ square meters. I hereby affirm that this purchase combined with all of my other land holdings in the Philippines do not exceed 1,000 square meters aggregate.

4. I intend to use the aforementioned land for residential purpose upon my permanent return to the Philippines.

5. I am executing this sworn statement in compliance with Batas Pambansa Bln. 185 and its Implementing Rules and Regulations.

IN WITNESS WHEREOF, I have hereunto set our hand this ______day of ______at ______.

______Affiant

SUBSCRIBED AND SWORN to before me this ______day of ______at ______, affiant exhibiting to me his/her Community Tax Certificate No. ______issued at ______on ______

NOTARY PUBLIC