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Republic of the Philippines City of __________________

] ]S.s.

AFFIDAVIT I, Dr. _________, Filipino, of legal age, (single / married / widow), and a resident of _________, Philippines, having been duly sworn in accordance with law, hereby depose and state: That I am a duly-license medical doctor, practicing at _________ (Hospital/Clinic) with Professional License No. _________issued on ____________at ___________. That on or about __time__ of __date__, I personally attended to a patient named _____________ in giving birth by (normal delivery/caesarian section) to a baby (boy/girl) whom they named as _________; That I execute this Affidavit to attest to the truth of the foregoing facts and for any other legal purpose that this Affidavit may serve. IN WITNESS WHEREOF, I have hereunto set our hands this ___________,at ___________, Philippines.

_____________________ AFFIANT SUBSCRIBED AND SWORN to before me, this _____________, by _____________ who exhibited to me (his/her) Community Tax Certificate No. _____________ issued at _____________, Philippines on _____________. Doc. No. ______; Page No. ______; Book No. ______; Series of______;