Republic of the Philippines

)
: S.S.
______________________ )

AFFIDAVIT

I, JUVILYN GARCIA DE ROXAS, of legal age, single, Filipino and presently

residing at Barangay Sto. Nino, Modesta Village, San Mateo, Rizal, after having been duly
sworn in accordance with law, hereby depose and state, THAT:

1. I was civilly registered under the name JUVILYN GARCIA DE ROXAS; attached is
a copy of my Certificate of Live Birth issued by the Civil Registrar herein marked as
Annex “A” and made an integral part of this Affidavit;

2. I have been using the name Juvilyn G. De Roxas in all my school records as well as
in all my employment records;

3. I was baptized as a Christian in rites held at the St. Ignatius Pro-Cathedral, Military
Vicariate of the Philippines, on the 25 th day of December 1980; that due to an obvious
typographical error, the name indicated in the Certificate of Baptism issued by the
said church was JUBILYN G. DE ROXAS;

4. The names JUVILYN GARCIA DE ROXAS as appearing in my birth certificate and

in my other documents, and JUBILYN GARCIA DE ROXAS as appearing in my
baptismal certificate, are one and the same;

5. I am executing this affidavit to attest and declare as to the truth of the foregoing facts
and for whatever legal purpose that this Affidavit may serve.

IN WITNESS THEREOF, I have hereunto affix my signature this ______ day of

________________ 2013, at ___________________, Philippines.

JUVILYN G. DE ROXAS
Affiant

SUBSCRIBE AND SWORN to before me this _____ day of ________________ 2013.

Doc. No. ______;

Page No. ______;
Book No. _____;
Series of 2013.