REPUBLIC OF THE PHILIPPINES)

CITY OF ________________________) S.S.
x---------------------------------x
  
AFFIDAVIT 

I, ___________________________, of legal age, married, Filipino, and with

residence at ________________________________________, after being duly sworn
to in accordance with law, depose and state:

1. That I am married to ______________________ on _____________________

at the City of _________________________, Philippines. A machine copy of
Marriage Contract is hereto attached as ANNEX “A”;

2. That out of that marriage I bare five (5) children by the name of
_________________________, __________________________,
________________________, ________________________, and
________________________. A machine copy of their Birth Certificates are
hereto attached as ANNEX “B”;

3. That sometime in _____________________ my husband and I decided to

get separated, and a settlement was reached at
_____________________________ in respect to the aforesaid separation;

4. That since then, there has been no communication between us, nor
have I any knowledge of his whereabouts;

5. That I bore one son/daughter and three sons/daughters after my

husband and I separated, to wit:

A. __________________________ who was born on ___________________

B. ___________________________ who was born on __________________
C. __________________________ who was born on __________________
D. __________________________ who was born on __________________
A machine copy of their Birth Certificates are hereto attached as
ANNEX “C”;

6. I attest to the truth of the foregoing statements to the best of my own

personal knowledge and based on authentic documents or records. I
am executing this Affidavit for all lawful intents and purposes it may
serve.

IN WITNESS WHEREOF, I have hereunto set my hand this _______ Day

of ___________________ in _________________ City, Philippines.

__________________________

Affiant

 BEFORE ME A NOTARY PUBLIC for and in the above jurisdiction

personally appeared, ____________________________, known to me to be the same
person who executed the foregoing instrument which he/she acknowledged to
be his/her free act and deed.
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 2019