REPUBLIC OF THE PHILIPPINES..

)
CITY OF CAGAYAN DE ORO )S.S.

AFFIDAVIT

I, ROSALIO/ROSALEO LOPEZ, of legal age, widower, and a resident of

__________________, Philippines, having been duly sworn in accordance with
law, hereby depose and state, that:
1. My name is ROSALIO/ROSALEO LOPEZ as evidence by my birth
certificate/marriage contract, as herein attached as Annex A;
2. The name ROSALIO/ROSALEO LOPEZ was only a clerical error upon the
execution of the E1 FORM/CLD1.3A;
3. I am the father of the deceased NORMA LOPEZ MALANA whose death
was on September 12, 2012;
As such, I am executing this Affidavit to attest to the truth of the
foregoing facts and for any other legal purpose that this Affidavit may serve.
IN WITNESS WHEREOF, we have hereunto set our hands this __________
of June ___, at Cagayan de Oro City, Philippines.

_________________________
Affiant

SUBSCRIBED AND SWORN TO before me this __________ of June ___, at

Cagayan de Oro City, affiants exhibited to me their
(Cedula/Government ID
with number)
.

Doc. No. _____

Page No. _____
Book No. _____
Series of 2014.