REPUBLIC OF THE PHILIPPINES )

PROVINCE OF BULACAN ) S. S.
MUNICIPALITY OF BALIWAG )

AFFIDAVIT OF CHANGE OF CIVIL STATUS

I, LOVELY CASTILLANO BALBOA-CLEMENTE, of legal age, Filipino

citizen and a resident of 734 Sitio 4, Bahay Pare, Candaba, Pampanga, after
being duly sworn to in accordance with law do hereby deposes and says:

1. That I am presently employed as Teacher 1 at Bahay Pare National High

School at Sitio 2 Bahay Pare, Candaba, Pampanga;

2. That I am requesting Department of Education, Regional Office of

Pampanga at the City of San Fernando, Pampanga and other concerned
government/ offices to change my name LOVELY CASTILLANO BALBOA
to LOVELY BALBOA CLEMENTE and civil status SINGLE to MARRIED
in their official records by reason of my marriage to MARVIN SAGUM
CLEMENTE;

3. That hereto attached is certified true copy of my certificate of marriage,

solemnized before Rene E. Maglanque on June 30,2021 at Office of the
Municipality of Candaba, Pampanga;

4. That the above-mentioned attached certificate of marriage is genuine

and not spurious/fake and was validly issued by the proper authority;

5. That the foregoing statements/documents are goven/ submitted under

IN WITNESS WHEREOF, I have hereunto set my hand this 9th day of

November, 2021, at Baliwag, Bulacan.

MINA SANTIAGO MERCADO

Affiant
Unified Multi-Purpose ID No.
0002-2306997-0

SUBSCRIBED AND SWORN TO before me this 9th day of November,

2021, at Baliwag, Bulacan. Affiant exhibited to me his identification card
bearing her photograph and signature appearing therein. And I am convinced
that she and the affiant is the same person.

Doc. No. 519;

Page No. 105;
Book No. I;
Series of 2021.