REPUBLIC OF THE PHILIPPINES }

_____________________________ } S.S.

AFFIDAVIT OF SINGLE STATUS

I, _____________________________, Filipino, of legal age, single, with address at

_____________________________, after being duly sworn to in accordance with law, hereby depose and
state that:

1. I have never entered into any form of special contract of permanent union with any person for
the establishment of conjugal and family life;

2. I therefore confirm and affirm that my civil status as of this date is single and unmarried;

3. I have no knowledge of the existence of any record in any Civil Registry of the Philippines
which states the fact of my marriage;

4. I am executing this Affidavit to attest to the truth of the foregoing facts and for whatever legal
purpose it may serve;

IN WITNESS WHEREOF, I have set my hand this _____________________________in

Poblacion, Mabini, Batangas, Philippines.

_______________________________________

Affiant

SUBSCRIBED AND SWORN TO before me, on the date and place above-mentioned by
the affiant who exhibited to me specified competent evidence of identity as written under the
name, and as required under the 2004 Rules on Notarial Practice, as amended by A.M. No. 02-8-
13-SC.

Notary Public