AFFIDAVIT
REPUBLIC OF THE PHILIPPINES)
CITY OF ____________________) S.S.
I, _______________________
Name of consignee , of legal age, Filipino
citizen, in my capacity as consignee of the Shipment, with address at
___________________________________________________________________
Consignee’s address as per Bill of Lading
___________________________________________________________________ after
having been duly sworn to in accordance with law, do hereby depose and say:
(1) That the shipment on board the vessel/aircraft ________________
Carrier/Vessel number covered by
AWB/BL No. ___________________
BL/AWB as per attached document valued at Currency
________________________consist
w/ Value as declared in DOF form 91 of
personal and household effects;
(2) That these personal and household effects are owned by me and were
necessary and appropriately used for the comfort and convenience during my stay
abroad;
(3) That these personal and household effects are accompanying me on my return
or arriving within a reasonable time therein, barring unforeseen and fortuitous events,
shall not exceed sixty (60) days;
(4) That these personal and household effects are not in commercial quantities;
(5) That these personal and household effects are not intended for barter, sale or
for hire;
(6) That these personal and household effects are limited to the FCA and FOB
value ofAmount
__________;
(Please indicate the applicable amount; You may refer to Annex for reference.)
(7) That I have stayed in __________
Place of Work for __________________
Indicate months/years of stay and;
[If you did not stay in a foreign country for at least six (6) months, please state the reason
for the previous return in the Philippines]
(8) That I have not availed of the privileges within six (6) months from my arrival;
(9) That in addition to the privileges granted under the immediately preceding
paragraph, an additional one hundred fifty thousand pesos (P150,000.00) of tax and duty-
free exemption will be availed for home appliances and other durables, limited to one of
every kind accompanying me on my return, or arriving within a reasonable time which,
barring unforeseen and fortuitous events, in no case shall exceed sixty (60) days after my
return upon presentation of my original passport at the port of entry;
(Please indicate this provision only if you will avail the additional privilege. Please note
that this only covers home appliances and other durables)
(10) That I worked as ______________
designation
for ______________________located
Company at
_________
Place of work from _____
Date to _____,
Date as evidenced by my certificate of employment herein
attached;
(11) That I arrived in the Philippines on _____________________,
Latest date of Arrival coming from
_______________;
Country of Origin/Abode
(12) That I am applying for the tax and duty exemption pursuant to the provisions
of Section 800 (f) of CMTA and Section 109 (c) of the NIRC, as amended;
(13) That the Department of Finance is not liable for any misdeclarations on the
shipment by the consignee/applicant;
(14) That I am executing this affidavit to attest to the truth of the foregoing facts to
clear this shipment according to Customs procedures on the matter.
In witness whereof, I hereunto set my hands this __ day of ________ 20__.
_______________________
Affiant
SUBSCRIBED AND SWORN TO BEFORE ME, this___day of _______20___ in
_______________ affiant exhibited his/her __________________________.
Indicate exact Government ID Issued
Doc. No. _________
Page No. _________
Book No. _________
Series of _________
NOTE: **Additional information may be required depending on the legal basis of your application.
ANNEX
Personal and Household Effects limited to the FCA and FOB value of the following:
(i) Three hundred fifty thousand pesos (P350,000.00) [if the applicant have stayed in
a foreign country for at least ten (10) years and have not availed of this privilege
within ten (10) years prior to the applicant’s arrival;]
(ii) Two hundred fifty thousand pesos (P250,000.00) [if the applicant have stayed in a
foreign country for a period of at least five (5) but not more than ten (10) years and
have not availed of this privilege within five (5) years prior to the applicant’s
arrival;]
(iii) One hundred fifty thousand pesos (P150,000.00) [if the applicant have stayed in a
foreign country for a period of less than five (5) years and have not availed of this
privilege within six (6) months prior to the applicant’s arrival.]
