(Caption and title of case)

REPUBLIC OF THE PHILIPPINES

PROVINCE OF _______________
MUNICIPALITY OF ___________

I, ___________________, of legal age, single/married and resident of

__________________, after being sworn in accordance with law, depose and say:

That I am the plaintiff in the above-entitled case;

That I sufficient cause of action exists against the defendant named therein;

That this action is one of those specifically mentioned in Sec. 1 of Rule 57 of the
Rules of Court, whereby a writ of preliminary attachment may lawfully issue; namely:
(here state the nature of the suit which should be one of the six causes of action
mentioned in Rule 57, Sec. 1, Revised R.C.);

That there is no sufficient security for the claim sought to be enforced by the
present action;

That the amount due to the plaintiff in the above-entitled case is as much as the
sum for which an order of attachment is herein sought to be granted, above all legal
counterclaims on the part of the defendant.

____________, this __________ day of ________________, 200__.

____________________________
(Plaintiff)

SUBSCRIBED and sworn to before me, in the city/municipality of

_______________, this _______ day of _____________, 200_ by ____________ with
Community Tax Certificate No. _________________ issued at ________________ on
__________, 200_.

NOTARY PUBLIC
My commission expires on Dec. 31, 200_

Doc No. ______;

Page No. ______;
Book No. ______;
Series of 200__.