REPUBLIC OF THE PHILIPPINES)
) S.S.
I, (Name), of legal age, Filipino, married and a resident of (Address), after having been duly sworn to in accordance with law, depose and state:
1. I am the same person who executed the long form signature appearing on my (Description of Identification Card or Document) under the name (Name of Affiant), and who executed the short form signature appearing on some official documents including those appearing on (Description of Documents where the different signature appears).
2. Both long and short form signatures as they appear in said official documents are therefore executed by one and the same person, the undersigned affiant, as I used the long form and at other times used the short form when I signed official documents, exercised my employment and transact with offices or agencies.
3. I agree to indemnify and hold (Name of Agency or Institution) and their respective officers, employees, and agents harmless from and against any liability incurred by said agency/institution for relying in good faith upon the declaration provided in this affidavit.
4. I am executing this affidavit to attest to the truth of the foregoing facts and to explain the difference in my signatures.
IN WITNESS WHEREOF, I have hereunto set my hand this (Date) in (Place), Philippines.
(Name)Affiant
SUBCRIBED AND SWORN TO before me this (Date) in (Place), Philippines by (Name of Affiant) affiant exhibiting to me his Competent Evidence of Identity by way of Passport Identification (ID Number) issued on (Date) in (Place).
Notary Public
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 20__.