AFFIDAVIT OF SURVIVING SPOUSE

I, SP04 Albino Lopez Cagasan, of legal age, Filipino, and resident of Blk. 31 Lot 1,
NHA Phase 2, Kauswagan, Cagayan de Oro City, after having been duly sworn to in
accordance with law, depose and state THAT:

1. I am a widower of Luzminda P. Cagasan, who died on February 6, 2017 at Madona

and Child Hospital, Cagayan De Oro City;

2. I hereby declare that, since the death of my spouse, I have not remarried, cohabited
with another person, or otherwise engaged in a common-law relationship.

3. I am executing this affidavit to attest to the truth of the foregoing statements and
for all legal intents and purpose that it may serve.

I fully understand that any inaccurate and untruthful statement in this affidavit shall
render me criminally and civilly liable.

IN WITNESS WHEREOF, I have hereunto set my hand

this ___________________ in Cagayan De Oro City, Philippines.

Albino Lopez Cagasan

Affiant

SUBCRIBED AND SWORN TO before me this ________________________ in

_________________, Philippines, affiant exhibiting to me his/her _____________________
as Competent Evidence of Identity (CEI).

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2017