SWORN STATEMENT

I, _______________________, of legal age, currently residing at

_______________________________________________________________, after having
been duly sworn in accordance with law, do hereby depose and state that:

1. I am retired and/or currently unemployed and have no source of income.

2. As such, I am not/no longer required to file an Individual Income Tax Return (ITR)

3. I am executing this Sworn Statement to attest to the truth of all the foregoing statements and for
whatever legal purposes it may serve.

4. I undertake to immediately inform HSBC and submit the ITR annually in the event that I have
income earned from sources within the Philippines. My failure to do so will be considered a
breach of the terms and conditions of my loan with HSBC.

IN WITNESS THEREOF, I have hereunto set my hand this ___ day of __________ 200_.

__________________________________________

Affiant (affix signature above printed name)

Republic of the Philippines )

City of __________ ) S.S.

SUBSCRIBED AND SWORN TO before me this ___ day of __________ 201__ affiant exhibiting
before me his/her Community Tax Certificate No. ____________________ issued on
___________________ at _____________________ and __________________________ I.D. issued on
_________________________ and will expire on _________________________.

Doc. No.

Page No.

Book No.

Series of 200__.

PUBLIC