Republic of the Philippines )

City/Municipality of __________ )
Province of_________________) S.S.

AFFIDAVIT
(of Declaration of Source of Income)

I, Justin Edward M. Hapa, Filipino, single, of legal age, and with residence address at
1359 Purok 1, Bambang, Bulakan, Bulacan, after having been sworn in accordance with the law,
hereby depose and state:

1. That I am unemployed as I am a student whose financial support is being provided by my

father, Jose Manuel C. Hapa, who is currently working as an overseas Filipino worker in the
United States of America;

2. That my father is working as a personal caregiver to Thomas Sadowski, resident of Malibu,

California, and that my father’s work arrangement under him is only on an informal basis and
thus not currently bound by a legal contract;

3. That my father is earning an annual gross income of 400,000 php;

4. That I am executing this Affidavit to attest to the truth of the foregoing and for the purpose of
applying for a student dormitory in the University of the Philippines Diliman.

IN WITNESS WHEREOF, I have hereunto set my hand this _________________day of

_______________, 2019 in ____________________________, Philippines.

___________________________________
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME this ____ day of _________, Affiant

exhibiting to me his/her Community Tax Certificate No. ______________, issued on ________
at ___________________ and __________ ID No. ______________ issued on ____________
in _________________.

NOTARY PUBLIC
Doc. No. _____;
Page No. ____;
Book No. ____;
Series of ____.