REPUBLIC OF THE PHILIPPINES ) Province of ____________________ ) S.S. City/Munici!"ity of ______________ ) #$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$# AFFIDAVIT AFFIDAVIT OF PUBLICATION
I% ________________&n!'e of !ffi!nt)____________ % Fi"i Fi"ii ino no%% of "e(!" !(e% *in("e+//'!rrie, *in("e+ to _________&n!'e of *ou*e) _________+% _________+% !n, ! re*i,ent of ___________________&!,,re** ___________________& !,,re** of !ffi!nt)_______________ % !fte !fter r -!vin( een ,u"y *orn in !ccor,!nce it- "!% -erey ,eo*e !n, *t!te0 1. T-!t I !' t-e C"!**ifie, 2,* M!n!(er of t-e ________&n!'e of ne*! ne*!er)______ er)_____________ _______ % u"i*-er of t-e -ic- i* ein( u"i*-e, ,!i"y in En("i*-% of (ener!" circu"!tion it- e,itori!" !n, u*ine** !,,re** !t __________________________________ ____________________ ______________ 3 4. T-!t !t t-e or,er of _____________ of _____________ % E#tr!5u,ici!" Sett"e'ent of E*t!te of t-e "!te _____________________ ,!te, ________________ !* !* u" u"i* i*-e -e, , in t-i* t-i* ne* ne*! !er er in it* it* _________ i**ue&*) i**ue&*) of __________________ of __________________ 3 IN 6ITNESS 6HEREOF% I -!ve -ereunto !ffi#e, 'y *i(n!ture t-i* ___ tt- ,!y of __________ of __________ % 47 ___ !t _____________ !t _____________ % P-i"iine*. _________________________________ ____________________ _____________ &Si(n!ture of 2ffi!nt over Printe, N!'e)
SUBS SUBSCR CRIB IBE8 E8 2N8 S6OR S6ORN N TO BEFO BEFORE RE ME% ME% ! not!r not!ry y u" u"ic ic in !n, !n, for _________&City/P _______ __&City/Province) rovince) ____________ ____________ tt-i* ____ t- ,! ,!y of of _______ ____________ _____ 47 ___ . 2ffi!nt 2ffi!nt er*on er*on!""y !""y c!'e !n, !e!re, !e!re, it- _______ _____________&Co ______&Co'etent 'etent Evi, Ev i,en ence ce of I, I,en enti tity ty)_ )___ ____ ___ _ i**ue, y t-e ______ _________&9over ___&9overn'ent n'ent 2(ency)______ 2(ency)_ _____ on ___&,!te ___&,!te)__ )__ !t _______ ________&"!ce)__ _&"!ce)________ _______ _ % e!ri e!rin( n( -i* -i* -oto(r!- !n, *i(n!ture% :non to 'e !* t-e *!'e er*on -o er*on!""y *i(ne, t-e fore(oin( in*tru'ent efore 'e !n, !voe, un,er en!"ty of "! to t-e -o"e trut- of t-e content* of *!i, in*tru'ent.
8oc. No. ____ No. ____ P!(e No. ____ No. ____ Boo: No. ____ No. ____ Serie* of 47 __
2tty _______ 2tty ______________ _____________ _____________ ______________ ____________ _____ Not!ry Pu"ic Co''i**ion Seri!" No. _______ No. ______________ ___________ ____ Not!ry Pu"ic for ____&Pro for ____&Province/C vince/City) ity) ______ ________ __ Unti" 8ece'er ;1% 47 __ Office0 _______ Office0 _________&!,,re __&!,,re**)_____ **)____________ __________ ___ Ro"" No. _______ No. __________ ___
IBP Lifeti'e Ro"" No. ________ 3 __/__/__ 3 &Province) PTR No. _________ 3 __/__/ __ 3 _&Province) _ MCLE Co'"i!nce Cert. No. __________ 3 __/__/__ <<< Note0 I**ue, y ! ne*!er !fter t-e u"ic!tion of ! "e(!" notice in it* !(e*. 1;uC8+
