REPUBLIC OF THE PHILIPPINES ]

CITY OF SAN FERNANDO, LA UNION ]S.S

AFFIDAVIT OF INDIGENCY

I,________________________, Filipino, of legal age, with residence and postal address at

________________________________, after having been duly sworn to in accordance with law, depose and
states, that:

1. We belong to the lower strata in life having no sufficient source of income;

2. My gross income and that of my immediate family do not exceed an amount double the
monthly minimum wage of an employee and that we do not own real property as could be
gleamed from the attached certification from the Assessor’s Office of ________;
3. Attached thereto also are the Certification of Indigency issued by the Barangay concerned as
well as the Office of the Department of Social Welfare and Development (DSWD);

I am executing this affidavit to attest to the truth of the foregoing and for whatever purpose it
may serve.

___________________________________
Affiant

SUBSCRIBED AND SWORN to before me this _____ day of _______________ at ______________________. Affiant
exhibited to me his ________________________ (ID Type) No. ____________ valid up to
_________________________.

___________________________
Notary Public
Doc. No. ________ UNTIL ___________________
Page No. ________ PTR NO. _________________
Book No. ________ ___________________________
Series of ________
REPUBLIC OF THE PHILIPPINES ]
CITY OF SAN FERNANDO, LA UNION ]S.S

AFFIDAVIT OF NO INCOME

We, _________________________ and _________________________, of legal age, spouses, Filipino citizens,

and residents of _________________________________________, after having been duly sworn to in accordance
with law, depose and say:

That we are the parents of ______________________________, incoming grade _____ of

______________________ (Name of School),________________________________________ (Address) for the school
year, _____;

That I, ___________________________, is a farmer and I, ______________________, is a plain housewife;

That our income is not enough to support the schooling of our son;

That we do not own any real property within the City of Sam Fernando or within the
province of La Union; and

That this affidavit is executed for SCHOLARSHIP APPLICATION of our child, and for all legal
intents and purposes;

IN WITNESS WHEREOF, we have hereunto affixed our signature this _____ day of _________ in
City of San Fernando La Union.

___________________________________________
Signature over Printed Name

___________________________________________
Signature over Printed Name

SUBSCRIBED AND SWORN to before me this _____ day of _______________ at ______________________. Affiant
exhibited to me his ________________________ (ID Type) No. ____________ valid up to
_________________________.

___________________________
Notary Public
Doc. No. ________ UNTIL ___________________
Page No. ________ PTR NO. _________________
Book No. ________ ___________________________
Series of ________
REPUBLIC OF THE PHILIPPINES ]
CITY OF SAN FERNANDO, LA UNION ]S.S

AFFIDAVIT OF NO PENDING CASE

I, ___________________________________, of legal age, married, Filipino citizen and a resident of

____________________________, after having been duly sworn to in accordance with law, hereby depose
and say:

That I am an applicant for retirement of the Department of __________________, Bureau of

____________, ___________________________________________ (Address).

That there is no pending criminal investigation against me with the said agency/office and
that I have never been arrested by any law enforcement agency, nor have I been accused or
convicted of any crime before any court or tribunal in the Philippines or abroad;

That this affidavit is executed to attest to the truth of all the foregoing facts and likewise for
all legal intents and purposes;

IN WITNESS WHEREOF, I have hereunto affixed my signature this _____ day of _______________,
at _____________________________________.

___________________________________
Affiant

SUBSCRIBED AND SWORN to before me this _____ day of _______________ at ______________________. Affiant
exhibited to me his ________________________ (ID Type) No. ____________ valid up to
_________________________.

___________________________
Notary Public
Doc. No. ________ UNTIL ___________________
Page No. ________ PTR NO. _________________
Book No. ________ ___________________________
Series of ________
REPUBLIC OF THE PHILIPPINES ]
CITY OF SAN FERNANDO, LA UNION ]S.S

AFFIDAVIT OF DISCREPANCY

I, ____________________________, of legal age, married, Filipino citizen, and a resident of

_______________________________________, under oath, do hereby depose and state:

That I was born on _________ at ____________________________, a copy of my Certificate of Live Birth

is hereto attached as Annex “A” and made an integral part of this affidavit;

That the name entered in my Certificate of Live Birth was ________________ and the same name
also appeared in my Certificate of Baptism issued by ___________________ of _________________________;

That the anme of my father is __________________________________________;

That however, in my Certificate of Confirmation issued by ___________ of ______________, my

name was entered as ___________________________ and the name of my father was also entered as
__________________________;

That I am executing this affidavit top attest to the truth of the foregoing facts that
________________________ and _____________________________, refer to one and the same person, which is me
and that _________________________ and _______________________refer to one and the same person, which is
my father;

This affidavit is also executed for all legal intents and purposes;

IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of _____________ in the
__________________________________________.

___________________________________________
Signature over Printed Name
Affiant

SUBSCRIBED AND SWORN to before me this _____ day of _______________ at ______________________. Affiant
exhibited to me his ________________________ (ID Type) No. ____________ valid up to
_________________________.

___________________________
Notary Public
Doc. No. ________ UNTIL ___________________
Page No. ________ PTR NO. _________________
Book No. ________ ___________________________
Series of ________
REPUBLIC OF THE PHILIPPINES ]
CITY OF SAN FERNANDO, LA UNION ]S.S

AFFIDAVIT OF TOTAL LANDHOLDINGS, NON-TENANCY AND

NON-EXISTING IMPROVEMENT

I, ____________________________, of legal age, married, Filipino citizen, and a resident of

_______________________________________, under oath, do hereby depose and state:

That I am one of the surviving heir being the daughter of the late SPOUSES
_______________________and ________________, declared owner of a parcel of land covered by OCT No.
__________ and registered under Tax Declaration No. ____________ containing an area of ____________ (____)
square meters located at _______________________________________________;

That at the time of their death this is the only property declared in their name within the
Municipality of _____. Even particularly on ______________ and on ____________ and no other property
declared in their name within the province of _____________;

That said property is not tenanted or leased by an agricultural tenant or lessee, the same
has no existing improvement found thereon, same is free from all liens and encumbrances;

That this affidavit is executed for all legal intents and purposes;

FURTHER AFFIANT SAYETH ONE.

IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of _____________ in the
__________________________________________.

___________________________________________
Signature over Printed Name
Affiant

SUBSCRIBED AND SWORN to before me this _____ day of _______________ at ______________________. Affiant
exhibited to me his ________________________ (ID Type) No. ____________ valid up to
_________________________.

___________________________
Notary Public
Doc. No. ________ UNTIL ___________________
Page No. ________ PTR NO. _________________
Book No. ________ ___________________________
Series of ________