AFFIDAVIT OF CIVIL STATUS

I, ___________________________________________________________, of legal age,

Filipino citizen, holder of Philippine Passport No. _________________ issued on
_____________________ at ______________________________ and presently residing at
_____________________________________________________________
_________ hereby depose and state:
1. That I was born on __________________________at ___________________
______________________________________________________________;
2. That I am ______________ (single and have never contracted marriage before
/widow/widower/divorced);
3. That I do not possess any legal impediment to contract marriage under the
laws of the Republic of the Philippines; and,
4. That I am executing this affidavit in connection with my forthcoming marriage
on _______________ at _______________________________.

___________________________
Affiant
___________________________________________________________________________

Embassy of the Philippines )

Brussels, Belgium
) s.s.

SUBSCRIBED AND SWORN to before me this ___________ day of

______________________________ at the Philippine Embassy in Brussels, Belgium.
Fee Paid : __________
O.R. No. : __________
Service No. : __________
Doc. No. : __________
Page No. : __________
Series of : __________