Republic of the Philippines)

Province of Cagayan
)s.s
City of Tuguegarao
)

AFFIDAVIT
RE: 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 Public
Doc. No. ___;
Page No. ___;
Book No. ___;
Series of 2015.