HQP-PFF-031

(V03, 08/2017)

File No. _________

SWORN DECLARATION OF INTENTION TO DEPART

FROM THE PHILIPPINES PERMANENTLY

I, ______________________________, of legal age, Filipino,

single/married,widow/er and with residence and postal address at
_________________________________________, after being duly sworn to in
accordance with law, depose and state that:

1. I am member of the Home Development Mutual Fund (Pag-IBIG Fund), with

Pag-IBIG MID No. _______________;

2. I am presently employed by/recently resigned from

______________________, with postal address at
_________________________________________________;

3. I am a holder of Passport No. _________________ issued by

___________________;

4. An immigrant’s visa has been issued to me by the Embassy of

_________________________________________________;

5. I am migrating/returning to ___________________________ and will stay

there permanently, being an immigrant citizen thereof;

6. I am leaving the country within sixty (60) days from date hereof;

7. In the event that my permanent departure from the Philippines shall not
materialize for any reason whatsoever, I hereby agree to return or refund the
amounts paid to me by the Fund on account of my approved application for
provident benefits; and

8. I am executing this affidavit to attest to the truth of my intention to depart from

the country permanently and to claim my provident benefits from the Fund
and for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ________th day of

____________________ at _________________________.

_____________________
AFFIANT

SUBSCRIBED AND SWORN to before me in the ___________________ this

____ day of ______________, __________ by ________________________, who has
satisfactorily proven to me his/her identity through his/her
_________________________ valid until ______________, that he/she is the same
person who personally signed before me the foregoing Sworn Declaration and
acknowledged that he/she executed the same.

NOTARY PUBLIC

Doc. No. ____________;

Page No. ____________;
Book No. ____________;
Series of _____________.