Republic of the Philippines)

) SS.

AFFIDAVIT
re: ART PROVENANCE

I, name, of legal age, married, and a resident of address hereby depose and state that:

1. The Untitled Artwork as shown below has the following details:

a. Artist :
b. Size :
c. Medium :
d. Circa :

2. Details.
3. Details.
4. I affirm, confirm, and undertake that all stipulations above are true and correct to the best of my
personal knowledge.
5. I execute this Affidavit to attest the veracity of the contents hereof and for all legal intent and purposes
it may serve.

AFFIANT SAYS NOTHING FURTHER

Name Name
Witness Affiant

SUBSCRIBED AND SWORN TO before me this__________ day of_______________ at City of

_______________, affiant exhibiting to me his Driver’s License with License number ID Number.

Notary Public
Doc. No. .........:
Page No. .........;
Book No. .........;
Series of 20__.