REPUBLIC OF THE PHILIPPINES )

CITY OF DAVAO ) S.S

I, _________________, of legal age, Filipino citizen, and a resident address at __________________,

after being sworn according to law, depose and state that:

1. I am the true and legitimate mother of ________________

2. My said son was born in _____________ Province of ___________________ Philippines, on the

_______ day of _________________, and is now ___________ year and _____________
months old.

IN WITNESS WHEREOF, etc.

_______________________

_____________________
Affiant