REPUBLIC OF THE PHILIPPINES)

Baguio City………..……..………….) s.s.

AFFIDAVIT OF NON-RECEIPT OF INCOME

I, , of legal age, American Citizen, widow and a resident of No. , after
having been sworn in accordance with law, do hereby depose and state that:

1. I am already advanced in age and therefore no longer work for a

living;

2. Despite my being retired, I am neither receiving any income from the

governments of the United States nor the Republic of the Philippines;

3. I am executing this Affidavit for the purpose of attesting to the

truthfulness and veracity of the foregoing statements and in
compliance with the requirements of the National Visa Centerand the
United States Embassy relative to my daughter’s immigrant
application.

AFFIANT FURTHER SAYETH NAUGHT.

Affiant

SUBSCRIBED AND SWORN to before me on this ______________ at

Baguio City, Philippines with affiant exhibiting to me issued on at the City of
Baguio.
.

Doc. No.: ____

Page No.:____
Book No.:____
Series of 2018