REPUBLIC OF THE PHILIPPINES )

QUEZON CITY ) S.S.

AFFIDAVIT OF NON-FILING OF INCOME TAX RETURN

I, ________________________, _____years old, married, Filipino

and a resident of ___________________________________________, after
having been duly sworn to in accordance with law, depose and says
that:

1. I am currently unemployed;

2. I do not receive any form of salary;

3. I am not required to file an Income Tax Return;

4. I am executing this affidavit for the application of

scholarship of ______________________ at the QUEZON CITY
POLYTECHNIC UNIVERSITY;

5. That I am attesting to the truthfulness and veracity of the

above statements and for any legal purpose which this may
serve.

_______________________
Affiant

SUBSCRIBED AND SWORN to before me 27th day of May 2015

herein Quezon City. Affiant exhibited to me her
_______________________ with number
______________________________ bearing her signature and
photograph as competent evidence of identity.