STATUTORY DECLARATION
I, ___________________________________, a citizen of the Philippines,
single/married/widow/widower, with residence and postal address at
________________________________________________________________________
________________________________________________________________________
do hereby solemnly declare under oath:
1. That I am a citizen of the Philippines;
2. That I have been a permanent resident in Australia since
_____________________________________________________________;
3. That during the Philippine taxable year 19__ (calendar year
January to December), I was unemployed in Australia and had
no other source of taxable income elsewhere;
4. That during the period referred to above, I was a dependent of
_____________________________________________________________
(state relationship)
5. That I have executed this Statutory Declaration for presentation
to the Embassy of the Philippines in Canberra, Australia, in
support of my request for the issuance of a Certificate of
Unemployment for travel tax exemption in connection with
my forthcoming trip to the Philippines on _______________
and return to Australia on _______________.
_____________________
Affiant
SUBSCRIBED AND SWORN to before me this ____ day of ____________, 19___.
________________________
Commissioner of Oaths/
Notary Public
(Please print name, address and
affix signature and seal, if any)
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