Republic of the Philippines)

Las Pias City

) s.s.
AFFIDAVIT OF SINGLENESS
I, CHARLENE MAE GALONO BALSOMO, of legal age, single, Filipino
citizen, with residence and postal address at 337 Magsaysay Street,
Poblacion, Belison, Antique, Philippines, after being duly sworn in
accordance with law hereby depose and say, that:
1. My full name XYZ;
2. I am 23 years old and a Filipino citizen;
3. I was born on May 5, 1985 at San Jose, Antique, Philippines;
4.

I am presently residing at xxx philippines

5. My fathers name is XY;

6.

He is residing at xxx
7. My mothers name is x;

8. She is residing xxx

I am executing this affidavit to establish my real identity and
hereby declare and attest that I am SINGLE and never been married.
FURTHER AFFIANT SAYETH NAUGHT.

Affiant
SUBSCRIBED AND SWORN TO before me this 16 February 2009 at
Las Pias City, Philippines, affiant exhibiting her Community Tax
Certificate No. 17900645 issued on 07 May 2008 at Belison, Antique,
Philippines.

Doc. no. 100

Page no. 21
Book no. 1
Series of 2009