REPUBLIC OF THE PHILIPPINES )

CITY OF TUGUEGARAO )S.S

PROVINCE OF CAGAYAN )

AFFIDAVIT

I, JOSEFINA CAPILI FLORENTINO, of legal age, Filipino and a resident of

AFUSING, Daga Alcala, after having been duly sworn in accordance with law,
do hereby depose and state:

1. That I went at the Office of the Philippine Statistic Authority,

Tuguegarao City to request for the issuance of birth certificate of my
brother SAMSON CAPILI who died on April 10, 2018;
2. That before I could secure said document, the Office have asked me to
execute a Special Power of Attorney;
3. However, records show that SAMSON CAPILI died without any wife or
children who could give me their authority to secure the same;
4. Moreover, our parents, EMILIANO CAPILI and INNOCENCIA APOSTOL-
CAPILI, have already died and therefore cannot give their consent
appurtenant thereto;
5. Hence, I am executing this Affidavit to attest to the truthfulness and
veracity of the foregoing and to support my request to secure a copy of
my brother’s birth certificate SAMSON CAPILI;

IN WITNESS WHEREOF, I have hereunto set my hand this

____________________ at Tuguegarao City, Cagayan.

JOSEFINA CAPILI FLORENTINO

Affiant

SUBSCRIBED AND SWORN to before me this ________________________ by

affiant who exhibited to me her OSCA ID with Control No. 17-08-4756 as
competent proof of her identity.

Doc No.______:
Page No._____:
Book No._____
Series of 2018.