Republic of the Philippines)

City of ________________)
x- - - - - - - - - - - - - - - - - - - x

AFFIDAVIT OF COHABITATION
(for change status in Certificate of Death)

I, ___________________, of legal age, Filipino and resident of

__________________________ and having been duly sworn in
accordance with law, hereby depose and state:
1. That I am the common-law wife of the late ______________
and we live together as husband and wife under the same roof,
continuously and without any interruption, since years 1973;
2. That my common-law husband died on August 15, 2018 at
___________ and his facts of death was to be registered with
the City Civil Registrar of _____________;
3. That however, it was discovered that during preparation of the
Certificate of Death, I erroneously supplied his civil status as
WIDOW, instead of SINGLE and my status as informant I
supplied WIFE, instead of LIVE-IN-PARTNER or COMMON-
LAW-WIFE for we were not married and we remained single
though there exist no legal impediment for us to marry each
other;
4. That I would like to correct said erroneous information in the
prepared Certificate of Death so as to reflect the correct
information before it is registered with the City Civil Registrar of
_________________;

5. That I am executing this affidavit to attest to the truth of the

foregoing and for whatever legal purposes it may serve;
IN WITNESS WHEREOF, we have set our hands this
_____________ at _______________________.

___________________
Affiant

SUBSCRIBED AND SWORN to before me this __________ at

_________________ by affiant who exhibited to me her competent
identification as shown above.