REPUBLIC OF THE PHILIPPINES)

) Sci.

AFFIDAVIT OF SEPERATION
KNOW ALL MEN BY THESE PRESENTS:

I, _______________________, Filipino, of legal age, with residential

address at _______________________, after having been sworn in accordance
with law hereby depose and state:

1. That I have been married to _______________________ on September

8, 1996, at _______________________;

2. That I was physically separated from him for eight (8) years since March
25, 2014.

3. That all my statements are true and because of No Divorce Law in the
Philippines.

That I am executing this Affidavit to attest to the truth of all the foregoing
and for all legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunder affixed my signature this

_______________________, at _______________________, Philippines.

_______________________

SUBSCRIBED and SWORN to before me this _______________________,

affiant exhibiting to me her SSS ID No. _______________________ issued by the
Social Security System as competent proof of her identity.

NOTARY PUBLIC
Doc. No. ___;
Page No. ___;
Book No. ___;
Series of 2022.