REPUBLIC OF THE PHILIPPINES)

PASAY CITY, METRO MANILA ) S.S

AFFIDAVIT

I, TERESITA BELMONTE DE LEON, Filipino, widowed, of legal age, and with

postal address at Unit 1923, Studio Zen Private Dormitel and Residences, Taft Avenue,
San Isidro, Pasay City, after having duly sworn to in accordance with law, do hereby
depose and say:

1. That my maiden name was TERESITA ARCANGEL BELMONTE;

2. That I completed my primary education at San Isidro Elementary School, San

Isidro, Lupao, Nueva Ecija during the School Year 1961 1962;

3. That upon my inquiry for the issuance of Form 137, the said school cannot
provide a copy of the said document due to the fact that it was already old
aged and destroyed by termites. A certificate from the school is hereby
attached as ANNEX A;

4. That I am executing this affidavit to affirm and confirm the statements above
stated and in order to request for corrections in my birth certificate;

AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto set my hand this 27th day of November
2017 in Pasay City.

TERESITA BELMONTE DE LEON

Affiant
Senior Citizen ID No. 130171

SUBSCRIBED AND SWORN to before me this 27th day of November 2017 in

Pasay City, affiant exhibiting to me her Senior Citizens ID with bearing No. 130171,
issued at City of Manila on 13th day of April, 2015, described above as competent
evidence of her identity.

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Series of 2017