REPUBLIC OF THE PHILIPPINES)

City of Manila ) S. S.

AFFIDAVIT

I, ROMEO ROXAS MARQUICIAS, of legal age, Filipino Citizen, Married with

residence address at No. 026 Camelia Street, De Castro Subdivision, Paseo De Blas,
Valnzuela City, Metro Manila, after having been duly sworn to in accordance with
law, do hereby depose and state:

1. That sometime May 2011, I have undergone surgical operation for

mole removal at Chinese General Hospital, Blumentrit, Manila which was
conducted by a certain Dr. Cua, who is a Resident Surgeon of said Hospital;

2. That in Passport, my photograph appearing therein bears a mole on

the right side of my face near the nose and, resultantly, the same vanished from
said part of my face due to said removal operation;

3 That execute this Affidavit to attest to the truth of the foregoing

facts, for the purpose of renewing my Philippine Passport bearing No. EB0507820
with the Philippine Department of Foreign Affairs and for whatever legal intents
and purposes this may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 9th day of

December 2014 at the City of Manila, Philippines.

ROMEO ROXAS MARQUICIAS

Affiant

SUBSCRIBED and SWORN to before me this 9th day of December

2014, Affiant, exhibiting to me His Philippine Passport bearing No. EB0507820
issued by the Philippine Department of Foreign Affairs, DFA SM Manila Office on
July 3, 2010, valid until July 2, 2015 and Driver’s License No. N19-89-010236
issued by the Land Transportation Office, LTO, Malabon City, Metro Manila with
expiry date 2015-11-17. .

NOTARY PUBLIC
Doc. No. _______
Page No. _______
Book No. _______
Series of 2014