REPUBLIC OF THE PHILIPPINES )

Province of____________________) S.S.

City/Municipality of______________)
x---------------------------------------x

AFFIDAVIT OF FREE STATUS (Single Status Certificate)

I, ________________(name of affiant)____________, Filipino, of

legal age, [single]/[married to _________(name of
spouse)_________], and a resident of
___________________(address of affiant)_______________, after
having been duly sworn in accordance with law, hereby depose and
state:

1. That I am the [brother]/[sister] of __________________ who

was born on ___________, in _____________________;

2. That I used to stay with my above-named [brother]/[sister]

until _______________ when I transferred to the above
address;

3. That as _______________‘s [bother]/[sister], I certainly know

[him]/[her] to be single and that [he]/[she] has never been
married before either civilly or in a religious ceremony;

4. That I am executing this affidavit in order to attest to the

veracity of the above circumstances and for the purpose of
compliance with the requirements of _________________ for
said [brother]/[sister]’s impending marriage in
__________name of church__________________ on
______date of wedding____________ to [Mr]/[Miss]
________________________.

5. Further Affiant sayeth none.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

____th day of ____________ 20___ at ____________, Philippines.

_______________(Signature of Affiant)__________________
(Printed Name)

SUBSCRIBED AND SWORN TO BEFORE ME, a notary public in and for

_________(City/Province)____________ this ____th day of ____________
20___. Affiant personally came and appeared with _____________(Competent
Evidence of Identity)______ issued by the _________(Government
Agency)______ on ___(date)__ at ________(place)_________, bearing his
photograph and signature, known to me as the same person who personally
signed the foregoing instrument before me and avowed under penalty of law to
the whole truth of the contents of said instrument.

Atty _______________________________________
Notary Public
Doc. No. ____ Commission Serial No. __________________
Page No. ____ Notary Public for _______(Province/City)_____
Book No. ____ Until December 31, 20__
Series of 20__ Office: ______________(address)__________
Roll No. __________
IBP Lifetime Roll No. ________; __/__/__ ; (Province)
PTR No. _________ ; __/__/__ ; _(Province)_
MCLE Compliance Cert. No. __________; __/__/__

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