REPUBLIC OF THE PHILIPPINES )

) S. S.

SWORN STATEMENT AS TO THE [EXISTENCE/NON-EXISTENCE] OF BENEFICIAL OWNERS

I, [name of affiant], of legal age, Filipino, and with office address at [address], under oath, state that:

1. I am the duly elected and qualified Corporate Secretary of [name of Corporation] (the
Corporation), a corporation duly organized and existing under the laws of the Philippines,
with principal office address at [address];

2. Based from the records of the Corporation in my possession, I certify that: Comment [STL1]: Tick one and complete the
details, if necessary

no shares of stock of the Corporation is registered in the books of the Corporation in

trust for another person;
the following shares of stock of the Corporation is registered in the books of the
Corporation in trust for another person:

Name of Registered Name of Beneficial Owner No. of Shares

Shareholder

IN WITNESS WHEREOF, I have hereunto set my hand, this ________ at _________________, Philippines.

[NAME OF AFFIANT]
Corporate Secretary

SUBSCRIBED AND SWORN to before me, this _______________ at ____________, Philippines, affiant
exhibited to me his _____________ issued on ____________ at ______________.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2012.