REPUBLIC OF THE PHILIPPINES)

PROVINCE OF QUIRINO)
MUNICIPALITY OF DIFFUN) S.S

AFFIDAVIT

I, MA DULCE AMOR L. JUGUILON, of legal age, married and with residence address at
Washington St, P7, Rosario, Santiago City, Isabela, after having been sworn to in accordance
with law, hereby depose and state THAT;

1. I am self-employed as I have no employer other than myself and derive income from my
physical and mental efforts as:

PHYSICIAN from 2008 until PRESENT at JUGUILON, PEDIATRIC AND

MEDICAL CLINIC, DIFFUN,
QUIRINO.
(Nature of Self-Employment) (Start) (End) (Where Conducted)

2. I have read and understood the contents herein and swear under the penalty or Perjury
pursuant to Article 183 of the Revised Penal Code; and Falsification pursuant to Section 28 (a)
of RA 1161, as amended (Social Security Law).

3. I am executing this Affidavit to attest to the truth of the foregoing and for the purpose of
applying for my Correction of my Birth Certificate.

IN WITNESS WHEREOF, I have hereunto set my hand this 18th day of FEBRUARY
2019 at Diffun, Quirino, Philippines.

MA DULCE AMOR L. JUGUILON

Affiant
PRC ID NO. 0080352

SUBSCRIBED AND SWORN TO BEFORE ME this 18th day of FEBRUARY 2019 at

Diffun, Quirino, Philippines.Affiant exhibiting to me his/her Community Tax Certificate No.
______________, issued on ________ at ___________________.

Doc. No. _____;

Page No. ____;
Book No. ____;
Series.______;