Republic of the Philippines )

City of _______________ )S.S

x- - - - - - - - - - - - - - - - - x

AFFIDAVIT OF CHANGE STATUS

I, _________________________, of legal age, married, Filipino and a resident of

_________________________ after having duly sworn to in accordance with law hereby
depose and state:

1. That I married Juan Dela Cruz on June 12, 1898. Copy of my marriage
certificate is hereto attached as Annex “A”;

2. That I took and passed the Board examination for Teachers on _________;

3. That in all the records that I submitted with the office of Professional
Regulatory Commission, my civil status is still single;

4. That I did not change my civil status when I took the board examination
considering that in all my school records, my civil status is still single;

5. That as such, in all my records with the Professional Regulatory Commission

my status is single and I am using the family name Bonifacio;

6. That, I have executed this affidavit to attest the truth hereof and to request the
Office of the Professional Regulatory Commission to change my civil status
from single to married and to change my family name with the family name of
my husband.

IN WITNESS WHEREOF, I hereby affixed my signature below this affidavit this

_____ day of _________________hereat ____________________.

GREGORIA BONIFACIO-DELA CRUZ

Affiant

SUBSCRIBED AND SWORN TO, before me this ____day of __________hereat

__________________.

Doc. No. ________;

Page No. ________;
Book No. _______;
Series of 20____