REPUBLIC OF THE PHILIPPINES)

___________________________ ) S. S.

AFFIDAVIT OF PERSONAL CIRCUMSTANCE

I, ______________________________, of legal age, ____________, Filipino, and a resident

of ____________________________________, after having been sworn to in accordance with
law, depose and say: THAT-

1. I have purchased a housing unit at _________________________ located at

_________________, Cagayan de Oro City, more particularly described as follows:

Transfer Certificate of Title No. _________________

(Insert Technical description)

2. I have been married to ___________________________ on ________________;

3. Sometimes in 2012, I have been living separately from him due to irreconcilable
differences;

4. Up until now, I lost communication and have no knowledge of his whereabouts;

5. I was thereafter left alone with the sole responsibility of paying the monthly amortization
up until the full payment of (Block Lot, Subdivision);

6. As such, I am executing this affidavit as required by the Registry of Deeds for the title
transfer of the above-mentioned property.

IN WITNESS WHEREOF, I hereunto affixed my signature this ______________ at

Cagayan de Oro City, Philippines.

NAME
Affiant

SUBSCRIBED AND SWORN TO before me this ____________at Cagayan de Oro

City, Philippines, affiant exhibiting to me her government issued id no.
_______________________ valid until _________________.

Doc. No. _____;

Page No._____;
Book No. _____;
Series of ______.