REPUBLIC OF THE PHILIPPINES )

BATANGAS CITY . . . . . . . . . . . . . )S.S.

AFFIDAVIT OF SEPARATION

I, _________________, of legal age, Filipino citizen, with residence

and postal address at ______________________, after having been duly
sworn to in accordance with law hereby depose and state,:

1. That I was married to ______________ on ________________;

2. That since the year 1983, we were already separated-in-fact;

3. I am executing this affidavit to attest to the truth of the

foregoing facts and circumstances and for whatever legal intents and
purpose/s this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 14 th day

of October 2021 at Batangas City.

_____________________
Affiant/________________

SUBSCRIBED and SWORN TO BEFORE ME this 14th day of

October 2021 at Batangas City.

Doc. No. ___;

Page No. ___;
Book No. ___;
Series of 2021.