Republic of the Philippines }

City of ___________ }Sc.

Affidavit of Family Composition

I, __________________________, Filipino citizen, of legal age, widow and
resident of ___________________________ after having been duly sworn to avers,
that:

1. My wife, _________________, and I got married on ______________

before the Office of the Municipal Judge and solemnized by the Honorable
__________________________;

2. Our union was blessed with four (4) children namely:

__________________________;

3. All our four (4) children are presently working and living in Italy including
their respective families except that of our youngest son ___________________ whose
family resides in ______________________;

4. Our daughter ________________ has married ______________.

____________________, on the other hand, is married to ________________ while
______________________ is married ________________. My son ______________
married ____________________________;

5. On _______________, my beloved wife had joined our Creator in the

great beyond;

6. Having been born on __________________, I am now sixty-eight (68)

years old. As such, I am no longer gainfully employed and has no more regular source
of income except the assistance coming from my children in Italy;

7. This affidavit of family composition is being executed to attest to the

truthfulness of all the foregoing allegations of facts and for all other legal purposes it
may serve.

In witness whereof we have hereunto affixed our signatures this ___________

day of _______________ in ____________________.

___________________
Affiant

Subscribed and sworn to before me a Notary Public for and in the

____________________________________ affiant exhibiting to me his Postal Identity
Card No. 8627588.

Witness my Hand and Seal this _____ day of ___________________

Doc. No.
Page No.
Book No.
Series of 2020