REPUBLIC OF THE PHILIPPINES)

_______________, METRO MANILA)S.S.

AFFIDAVIT

THAT I, XXXXXXXXXX, Filipino Citizen, of legal age, married and

presently residing at _____________________________, after being duly sworn
in accordance with law, depose and state that:

1. On March 10, 2012, I was married to XXXXXXXXXXXX in a catholic

church wedding ceremony in Xxxxxxxxxxxxx;

2. During our marriage, we were blessed with one (1) child, xxxxxxxx, (4)
years old, he was born on June 25, 2012;

3. I am now separated with my husband for more than one (1) year since
September 13, 2015, he abandoned us without providing any financial support
and I was left solo and alone with the responsibility of taking good care and
providing support for our children;

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

IN WITNESS WHEREOF, I have hereunto set my hand this

_______________________ at _____________________, Philippines.

xxxxxxxxx
Affiant

SUBSCRIBED AND SWORN TO before me, a Notary Public

commissioned in and for the ________________________, Philippines, this
_____________________ by the affiant who has satisfactorily proven to me her
identity through her __________________________________ and who
appeared and signed the foregoing AFFIDAVIT in my presence within my
jurisdiction, and who avowed to the truth of its contents under the penalty of law.

Doc No.______;
Page No._____;
Book No._____;
Series of 2016.