Republic of the Philippines)

Done in the City of Baguio ) ss.

AFFIDAVIT of INDIGENCY

I, _______________________________ , 64 years old, married, Filipino Citizen and

a resident of ____________________________________ after having been duly sworn to
in accordance with law do hereby depose and state:

1. That I am a Senior Citizen with ID No. ____________, a copy of my ID is

hereto attached as Annex “A”;

2. That I have no job or sufficient source of income;

3. That I am providing sustenance for my family through my monthly

pension of Seven Thousand Pesos (Php 7,000.00) only;

4. That I intend to file a Petition for Review before the Court of Appeals;

5. That I am executing this affidavit to attest to the truth of the foregoing

facts and to support my desire to avail of the exemption from the
payment of docket and other lawful fees before the Court of Appeals.

IN WITNESS WHEREOF, I have hereunto set my signature this 20th day

of November 2018, in the City of Baguio.

____________________________
Affiant

SUBSCRIBED AND SWORN to before me on the 20th day of November

2018 in the City of Baguio, the affiant exhibited to me his Senior Citizen ID
numbered _____________.

WITNESS MY HAND AND NOTARIAL SEAL.

Doc No. _______;

Page No. _______;
Book No. _______;
Series of 2018.