REPUBLIC OF THE PHILIPPINES)

City of Tacloban ) S.S.

AFFIDAVIT OF SINGLENESS

I____________________, Filipino, of legal age, single and a resident of

___________________________, Philippines, after having been duly sworn in
accordance with law, hereby depose and state:

1. That I have never entered into any form of special contract of

permanent union with any woman for the establishment of conjugal and
family life;

2. That I therefore confirm and affirm that my civil status as of this

date is single and unmarried;

3. That as such, I have no knowledge of the existence of any record in

any Civil Registry of the Philippines which states the fact of my marriage;

4. That I am executing this affidavit to declare the truth of the

foregoing facts and for the purpose of applying for a Marriage License
pursuant to the provisions of the Family Code of the Philippines.

IN WITNESS WHEREOF, I have hereunto set my hand this

__________________at ________________________________.

______________________
Affiant

SUBSCRIBED AND SWORN to before me, this _____________________ in

the _____________________by affiant who exhibited to me his LTO Driver’s
License with No. ____________________ and bearing his photograph and
signature, known to me to be the same person who executed the foregoing
affidavit.

Doc. No. ______;

Page No.______;
Book No. _____;
Series of 2019.