Republic of the Philippines )

Province of Leyte ) S.S.

Municipality of Villaba )
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AFFIDAVIT
OF CHANGE OF CIVIL STATUS

I, AGNES UY AMABAO, of legal age, married, Filipino and a resident of Villaba,

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

1. That I was born on April 20, 1962 at Villaba, Leyte, Philippines;

2. That my civil status at present is MARRIED;

3. That I married DANILO H. AMABAO, a Filipino citizen on June 9, 1985 at Holy Child
Parish, Villaba, Leyte, Philippines;

4. That my husband DANILO H. AMABAO died on November 01, 20015 in Villaba,

Leyte; and

5. That I have not entered into marriage with anyone since my husband died.

6. That this affidavit is being executed to attest to the foregoing facts for the specific
purpose of my application for Renewal/Amendment of Entries in the Alien Certificate of
Registration Identity Card (ACR I-CARD), specifically the change of my civil status from
MARRIED to WIDOW.

IN WITNESS WHEREOF, I have hereunto set my hand this 24th day of January, 2017
at Villaba, Leyte, Philippines.

________________________
AGNES UY AMABAO
Affiant

SUBSCRIBED AND SWORN to before me, this 24th day of January 2017 at Villaba,
Leyte, Philippines, by the Affiant who is personally known to me (or whom I have identified
through competent evidence of identity) and who exhibited her Alien Certificate of Registration No.
(A.C.R. No.) B 281701 issued at Manila, Philippines on April 11, 1980.

NOTARY PUBLIC
Doc. No. ______;
Page No. ______;
Book No.______;
Series of 2017.