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FPC013 File No. SWORN DECLARATION OF INTENTION TO DEPART FROM THE PHILIPPINES PERMANENTLY I of legal age single/married/widow/er and presently residing at after being duly sworn to in accordance with law depose and say 1. That I am a member of the Pag-IBIG Fund with Pag-IBIG ID No* 2. That I am presently employed by/recently resigned from postal address at 3. That I am a holder of Passport No* issued by 4. That an immigrant s visa has been issued to me by Embassy of 5. That I am migrating/returning to and will stay there permanently being an immigrant citizen thereof 6. That I am leaving the country within sixty 60 days from date hereof 7. That in the event my permanent departure from the Philippines shall not materialize for one reason or another 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. That I am executing this Affidavit for the purpose of attesting to the fact of my intention to depart from the country permanently and to claim my provident benefits from the Fund* Done this day of 20 at. Affiant SUBCRIBED AND SWORN to before me this day of at issued on at. NOTARY PUBLIC Doc* No* Page No* Book No* Series of. That I am a member of the Pag-IBIG Fund with Pag-IBIG ID No* 2. That I am presently employed by/recently resigned from postal address at 3. That I am a holder of Passport No* issued by 4. That an immigrant s visa has been issued to me by Embassy of 5. That I am a holder of Passport No* issued by 4. That an immigrant s visa has been issued to me by Embassy of 5. That I am migrating/returning to and will stay there permanently being an immigrant citizen thereof 6. That I am migrating/returning to and will stay there permanently being an immigrant citizen thereof 6. That I am leaving the country within sixty 60 days from date hereof 7. That in the event my permanent departure from the Philippines shall not materialize for one reason or another 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. That I am leaving the country within sixty 60 days from date hereof 7. That in the event my permanent departure from the Philippines shall not materialize for one reason or another 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. That I am executing this Affidavit for the purpose of attesting to the fact of my intention to depart from the country permanently and to claim my provident benefits from the Fund* Done this day of 20 at. That I am executing this Affidavit for the purpose of attesting to the fact of my intention to depart from the country permanently and to claim my provident benefits from the Fund* Done this day of 20 at. Affiant SUBCRIBED AND SWORN to before me this day of at issued on at. NOTARY PUBLIC Doc* No* Page No* Book No* Series of. That I am a member of the Pag-IBIG Fund with Pag-IBIG ID No* 2. That I am presently employed by/recently resigned from postal address at 3. That I am a holder of Passport No* issued by 4. That an immigrant s visa has been issued to me by Embassy of 5. That I am migrating/returning to and will stay there permanently being an immigrant citizen thereof 6.

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  • V01)
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