REPUBLIC OF THE PHILIPPINES)

QUEZON CITY ) SS

AFFIDAVIT

I, ________________, of legal age, Filipino, married, residing at

____________________________________, after being duly sworn to in accordance with law,
depose and state:

1. That I am married to __________________________;

2. That we lived together as husband and wife from __________________________;

3. That we have _______( ) children namely, _______________________________;

4. That my husband, ____________________________, left our home after a heated

argument sometime in _________________________________;

5. That from then on, until present, I never communicated with him, nor did he try to
communicate with me or our children;

6. I am executing this Affidavit to attest to the foregoing facts and for the purpose of
securing a Solo Parent ID, and to receive the benefits under the Solo Parents’ Welfare
Act of 2000.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 29th day of January
2020, in Quezon City Philippines.

_____________________________
Affiant

SUBSCRIBED AND SWORN to before me this 29th day of January 2020, in Quezon
City, Philippines, affiant exhibiting to me her competent evidence of identity indicated below her
printed name, bearing her picture and signature appearing therein. Further, she voluntarily signed
in my presence, this instrument affirmed under penalty of law, the whole truth of the contents
thereof.