Republic of the Philippines)

Republic of the Philippines)

Province of Cagayan )s.s

City of Tuguegarao

)AFFIDAVITRE: CHANGE OF CIVIL STATUS

I, ________________________________, of legal age, married, Filipino and a resident of ___________________________________, after having been duly sworn in accordance with law do hereby depose and say:

1. That I am the same __________________________________ who is the affiant herein;2. That my civil status appearing in my records with the National Statistics Office (NSO) is SINGLE whereas, my name appears as ____________________, my maiden name;

3. That I am now married, hence, my civil status in my records with the NSO should be changed from SINGLE to MARRIED and my name from ______________________ to ________________________; 4. That this change of status and name was made without intent of defrauding nor evading obligation which might result to fraud to contracts;

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

IN WITNESS WHEREOF, I have hereunto set my hand this ___ day of _________________, 2015 at Tuguegarao City, Philippines.

DAWN GOROSPE

Affiant

Govt Issued ID No._____;

Issued on: _____________;

At: ____________________SUBSCRIBED AND SWORN to before me this ___ day of ________________ 215 at Tuguegarao City, Cagayan, Philippines.

Notary PublicDoc. No. ___;

Page No. ___;

Book No. ___;

Series of 2015.