REPUBLIC OF THE PHILIPPINES)
_____________________ ) S.S.
AFFIDAVIT OF PERSONAL USE
I, (NAME OF AFFIANT), of
legal age, single/married, Filipino, and a resident of (Place of Residence), after having been duly sworn to in
accordance with law, hereby depose and state:
1.
That I intend to ship
the following products, to wit:
Amlife Tablet (Losartan
potassium, Amlodipine besilate), 50mg / 5mg Film-Coated Tablet at 50 tablets
per box X 3 boxes = 150 pieces; an antgiotensin II receptor antagonist / calcium
channel blocker / antihypertensive (medicine for hypertension)
1st Box: Lot No. _________
Exp. Date: JAN 2023
Mfg. Date: FEB 2020
2nd Box: Lot No. _________
Exp. Date: JAN 2023
Mfg. Date: FEB 2020
3rd Box: Lot No. _________
Exp. Date: JAN 2023
Mfg. Date: FEB 2020
2.
That the said products
will be transported from the Philippines to Los Angeles, California, USA.
3.
That the said products are intended for personal
use only and not for sale.
4. That
I execute this Affidavit to attest to the truth of the foregoing and for any
other legal purpose that this Affidavit may serve.
IN WITNESS WHEREOF,
I have hereunto affixed my signature this (Date) at (Place),
Philippines.
(NAME OF AFFIANT)
SUBSCRIBED AND SWORN TO BEFORE ME this (Date) by affiant (Name of Affiant) at (Place), Philippines, affiant exhibited to me her (ID Details and date of validity), a
government-issued ID bearing her signature and photograph.
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of _____.
