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Application Form Citizenship Retention And Re-Acquisition Form - Republic Of The Philippines - Embassy Of The Philippines, Seoul, South Korea Page 3

CERTIFICATION

I hereby certify under oath that all the information in this general application form composing

of two pages including the page on which this Certification is written are true and correct information

about myself as an applicant. I further warrant that I have complied with all the requirements of the

Bureau of Immigration with respect to my application for the issuance of Identification Certificate

(I.C.) and that I submitted duly certified true copies of documents issued under the official seal of the

officer having legal custody of their originals in the Philippines and foreign documents with their

official translation into English duly authenticated by the counsel / embassy official in the foreign

service of the Philippines in the foreign country, in compliance with the requirements of the Bureau

of Immigration. I understand that my application will not be processed by the Bureau if it finds any

statement herein to be false, if any document submitted is found to have been falsified, or if I fail to

comply with all the requirements of the Bureau of Immigration with respect to my application /

petition without prejudice to whatever action(s) the Bureau of Immigration shall take in accordance

with applicable laws of the Republic of the Philippines.

Date executed: _________________

Place Executed: Seoul City, Republic of Korea

_____________________________

(Applicant’s Signature over Printed Name)

Republic of the Philippines )

Embassy of the Philippines ) S.S.

Seoul, Republic of Korea

)

SUBSCRIBED AND SWORN TO before me this ____________ in the City of Seoul. Affiant

having exhibited to me his/her Passport No. __________ issued on ________ at ___________.

Doc. No.

Book No. 1

Page No.

Series of 2014

Application Form Citizenship Retention And Re-Acquisition Form - Republic Of The Philippines - Embassy Of The Philippines, Seoul, South Korea Page 3