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    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 _______________.


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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