REPUBLIC OF THE PHILIPPINES )

CEBU CITY ) S.S.

AFFIDAVIT

I, ___________________, of legal age, married, Filipino citizen, and a resident of

___________________, after having been duly sworn to in accordance with law hereby
depose and state that:

1. I am a registered Senior Citizen at the Office of the Senior Citizen Affairs

of City of Talisay;

2. On ___________________, a Senior Citizen Identification Card with

___________________was issued in my favor;

3. However, on ___________________, I contracted a marriage with

___________________ as evidenced by ___________________;

4. As such, I am executing this Affidavit to attest to the truth of the

foregoing circumstances for the purpose of updating my records in the
Office of the Senior Citizen Affairs of City of Talisay and for the purpose
of securing a new copy of my Senior Citizen Identification Card with
bearing the surname “___________________” and for whatever legal
intents and purposes this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand

this ___________________.

___________________
Affiant

SUBSCRIBED AND SWORN to before me this ___________________in Cebu

City, Cebu, Philippines, affiant having exhibited to me her competent evidence of
identity.

Doc. No. ___;

Page No. ___;
Book No. ___;
Series of 2019.