REPUBLIC OF THE PHILIPPINES )

PROVINCE OF NEGROS ORIENTAL )

CITY OF DUMAGUETE )

SWORN STATEMENT

I, ______________________________, Filipino citizen, of legal

age, single/married/widow(er), and with residence and postal
address at ________________________, Negros Oriental,
Philippines, after being duly sworn to in accordance with law,
hereby depose and state:

1. That I am still to engage in the farming of sugar cane on a

parcel of land situated at _________________, Negros
Oriental with an area of ____ hectare (s);

2. That I have not yet started planting sugar and my yearly

gross income does not exceed THREE HUNDRED
THOUSAND PESOS (Pph 300,000.00);

3. That I hereby declare under pain of perjury that my gross

income for CY 2016 does not exceed Php 300,000.00;

4. That I likewise declare that I have no other source of

income to augment my income from sugar cane farming,
it being my only means of livelihood;

5. That I am, executing this affidavit to attest to the truth and

veracity of the foregoing declaration and for whatever
purpose this may lawfully serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature

this __________, at Dumaguete City, Negros Oriental,
Philippines.

_____________________
Affiant

SUBSCRIBED AND SWORN TO before me this ______________ by

the affiant who exhibited to me his/her _____________ ID No.
______ and who avow the truth of the contents of the foregoing
instrument under penalty of law.

Doc. No. _____;

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