REPUBLIC OF THE PHILIPPINES ) ) S.S.

AFFIDAVIT
I, ______(NAME)_________, of legal age, Filipino, and with address at ______(address)_________, after having been duly sworn in accordance with law, do hereby depose and state that: 1. The name registered ______(NAME1)_________. in my Birth Certificate is

2. The name registered in my Confirmation Certificate as well as in my Baptismal Certificate is ______(NAME2)_________. 3. I was issued a Philippine Passport under the name ______(MARRIED NAME)_________ considering that at the time of my application, my marriage to ____(HUSBANDS NAME)______ has not yet been declared null and void. 4. In an Order dated ___(DATE OF ORDER)___, the Honorable __(NAME OF JUDGE)___, Presiding Judge of Branch ___ of the Regional Trial Court of ______________ has annulled my marriage to __(HUSBANDS NAME)__. 5. I have been using the name ______(NAME2)_________ ever since the said Order was issued. 6. ______(NAME1)_________, ______(NAME2)_________ and ______(MARRIED NAME)_________ refer to one and the same person. 7. I am executing this Affidavit to attest to the truth of the foregoing facts and for all legal intents and purposes. IN WITNESS WHEREOF, I have hereunto set my hand this ___st/nd/rd/th day of __(MONTH)__ _(YEAR)_ at ______ City.

(AFFIANTS NAME) Affiant SUBSCRIBED AND SWORN to before me this ___st/nd/rd/th day of __(MONTH)__ _(YEAR)_, affiant exhibiting to me her Passport/SSS/TIN. _______________ issued at ______________________ on _______________________.

Doc. No. _____; Page No. _____; Book No. _____; Series of 2011.