REPUBLIC OF THE PHILIPPINES )

Municipality of Kapalong )s.s

Province of Davao del Norte )
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AFFIDAVIT

I, xxxx, of legal age, Filipino, widow and a resident of, Davao del Norte, after having
been sworn to in accordance with law, hereby depose and say that:

1. I am the same person whose personal circumstances are described in the preceding
paragraph;
2. Upon verification with the Philippine Statistics Authority, the agency has no record of
marriage of E and N . A machine copy of the said Certification is hereby appended as
Annex “A”;
3. However, upon inquiry with the Local Civil Registrar of Carmen, Cotabato City, the
marriage between E and N on 1964 was recorded and encoded with Register No. xx.
Please refer to the photocopy of the said Marriage Contract attached as Annex “B”;
4. The Local Civil Registrar of Cotabato City is at present facilitating the forwarding of
the above record to the Office of the Civil Registrar General -Philippine Statistics
Authority of Manila;
5. I am executing this affidavit to attest to the truth of the foregoing facts and in
connection with my Japanese visa application.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 12 th day of March

2018 at Davao del Norte.

xxxx
Affiant

SUBSCRIBED AND SWORN to before me this 12 th day of March 2018 at Davao del
Norte, Philippines.