REPUBLIC OF THE PHILIPPINES

CITY OF BATANGAS ) S.S.

AFFIDAVIT OF SURVIVING SPOUSE

I, ________________________________, widower, of legal age, and a resident of

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

1. I am a widower of _____________________________________;

2. I hereby declare that, since the death of my spouse, I have not remarried, cohabited
with another person, or otherwise engaged in a common-law-relationship;

3. That I am executing this Affidavit to attest to the truthfulness of the foregoing facts
and for all legal purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ day of ___________
2023 at Batangas City, Philippines.

________________________________
Afffiant

SUBCRIBED AND SWORN TO before me this ___ day of _______________ 2023

at Batangas City, affiant exhibiting to me her ______________________________.

Doc. No. _____;

Page No. ____;
Book No. ____;
Series of 2023.