Republic of the Philippines )

City of Naga ) S.S.

AFFIDAVIT OF CHANGE OF STATUS

I, _____________________, of legal age, married and a resident of

_______________________________, after having been duly sworn in accordance with the law,
hereby depose and state, THAT:

1. I am the same _________________________, who is the affiant herein;

2. My civil status as appearing in the __________________________is single whereas my name

appears as ______________________________, my maiden name;

3. I am now married, hence my civil status in the _______________________ was stated as

married and name was changed to _________________________ to reflect my change of
status;

4. The change of status and name was made without intent of defrauding nor evading obligation
which might result to fraud to contracts;

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

IN WITNESS WHEREOF, I have hereunto set my hands this ____ day of ______________, 2018
in the City of __________________, Philippines.

___________________________
Affiant

SUBSCRIBED AND SWORN to before me this ____ day of ________________, 2018 in the City
of ________________, Philippines, affiant exhibiting to me her ______________________ as her
competent evidence of identity.

NOTARY PUBLIC