PHILIPPINE CONSULATE GENERAL }

OSAKA, JAPAN } S.S.

AFFIDAVIT OF CIVIL STATUS

I, _________________________________________ of legal age, Filipino citizen and

presently residing at _______________________________________________________
______________________________________, after having been duly sworn to in
accordance with law, do hereby depose and say:

1. That I was born on ____________________ at ______________________________;

2. That my civil status at present is DIVORCED;

3. That I married _______________________________, a ________________ citizen

on ______________________________ at _______________________________;

4. That we got divorced on __________________________ in

_______________________________; and

5. That I have not entered into marriage with anyone since I got divorced with my former
husband;

6. That this affidavit is being executed to attest to the foregoing facts for the specific
purpose of applying for welfare benefits and not to serve as a basis for marriage application.

In witness whereof, I have hereunto set my hand this _____th day of __________ 20__
at the Philippine Consulate General, Osaka, Japan.

________________________
Signature of the Affiant