REPUBLIC OF THE PHILIPPINES} S.S.

CITY OF ____________ }

AFFIDAVIT

I, MARY JEAN S. DE GUZMAN, of legal age, Filipino, married and a

resident of _________________________, after having been duly sworn to
in accordance with law, hereby depose and say that:

1. I was born on ______ at ______ to Spouses ______ and _______,

photocopy of my Certificate of Live Birth issued by the Philippine
Statistics Authority (PSA) is hereto attached as Annex “A”;

2. I am known by the name “____” and have used the same in my

personal and official records and interactions, as shown by the
following IDs:

Philippine Passport (Annex. “B”)

PRC ID (Annex “C”);

3. The names “________” and “_______” refer to one and the same
person;

4. I am executing this Affidavit to attest to the truth and of the foregoing

facts and to request the Local Civil Registry of ____ to change my
 given name from “______” to “_______” and to effect the necessary
corrections in my Certificate of Live Birth.

IN WITNESS WHEREOF, I have hereunto set my hand this __ day of

_____ 2021 in _________, Philippines.

________________
Affiant

SUBSCRIBED and SWORN to before me, this ___ day of _____,

2021, affiant exhibiting to me her ID with number _____ which is valid until
___.

NOTARY PUBLIC

Doc No. _______;

Page No. ______;
Book No. ______;
Series of 20 ____;