RPEUBLIC OF THE PHILIPPINES) ILOILO CITY )Sc.

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SWORN DECLARATION TO CLAIM TAX EXEMPTION FOR QUALIFIED DEPENDENT CHILD

I, JUANA DE LA CRUZ, of legal age, Filipino, married and resident of No. 37 Rizal St., Makati City, after having been sworn to in accordance with law, depose and state , that: 1. I am married but separated in fact from my husband, Pedro de la Cruz, who has abandoned me and our son for almost two (2) years already. I have lost all kinds of contact with him and do not know his whereabouts; 2. My husband has not provided any support either for me or for our son who is our only child since our separation and I have sole custody of the child; 3. As a solo parent, I am singlehandedly raising my son who is totally dependent on me for support; 4. I am presently employed and earning purely compensation income and I intend to file my income tax return on my taxable income separately from my husband; 5. In view of the foregoing and in accordance with the provisions of the National Internal Revenue Code, as amended, I am claiming my son, Jesus De la Cruz, three (3) years of age, born on 25 December 2009, as my qualified dependent child for purposes of additional exemption in my Income Tax Return with the Bureau of Internal Revenue; and 6. I hereby declare under penalty of perjury that the foregoing representations are true and correct and undertake to duly inform the Bureau of Internal Revenue for any change in the arrangement with regards to the support and custody of my declared dependent child.

IN WITNESS WHEREOF, I have hereunto set my hand in the city of Iloilo, Philippines, this ___________________ .

Juan De La Cruz Affiant SUBSCRIBED AND SWORN to before me this ___________________ , in the city of Iloilo, Philippines, affiant identified by me through her Competent Evidence of Identity: BIR Taxpayer I.D. No. 123-456-789 issued 26 May 2013.

Doc. No: ________ ; Page No: _______ ; Book No.: _______ ; Series of 2013.