The Consular Section of the Philippine Embassy in Tokyo, Japan assumes no responsibility for the contents of this document

Notarial Form 1(a) / GA

SINUMPAANG SALAYSAY
(Affidavit)

Ako, si _______________________________________________________, mamamayang Pilipino,

I, citizen of the Philippines
_____________________________________, may sapat na gulang at wastong pag-iisip, na kasalukuyang nakatira sa
[dalaga/binata/kasal/balo/diborsyado/napawalang-bisa ang kasal], of legal age and sound mind, presently residing at
______________________________________________________________________________________________
matapos manumpa sang-ayon sa batas, ay malaya at kusang-loob na nagsasabi:
after having been sworn in accordance with law, do hereby depose and say:

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Bilang patunay sa lahat ng ito, ako ay lumalagda ngayong ika-_____________________ dito sa Tokyo, Japan.
In witness whereof, I have hereunto affixed my signature this here in Tokyo, Japan.

________________________________
Lagda ng Nanunumpa at Nagsasalaysay / Affiant’s Signature
=====================================================================================================
Embahada ng Pilipinas sa Tokyo, Japan }
Seksyong Konsular }S.S.

PINANUMPAAN at NILAGDAAN sa aking harapan dito sa Tokyo, Japan, ngayong ika- ___________________________,
ng siyang nagsasalaysay, matapos ipakita ang kanyang [______________________] na may bilang ___________________, na
ipinagkaloob noong ______________________________ sa ______________________________.

Dokumento Blg :_________________

SVC Blg :_________________
Serye ng :_________________
Resibo Blg :_________________
Singil :_________________

Revised 15.08.2011/BDL