REPUBLIC OF PHILIPPINES )

CITY OF DAVAO ) S.S.

X -------------------------------------------------- X

AFFIDAVIT OF MARITAL SEPARATION

I, _, Filipino, marred, of legal age, and a resident of _, after being duly
sworn to in accordance with law, hereby depose and say that:

1. That I am a donor for the kidney transplant of my brother, _;

2. That in the said transplant, I was required to secure the

signature and consent of my spouse as a prerequisite thereof;

3. That I was married to _, but since 2016, I have not

communicated with him and have no knowledge of his
whereabouts;

4. That I exhausted all means to obtain information to locate him

to no avail such that at this point, it is almost impossible to
secure his consent as mandated by the hospital;

5. I am executing this affidavit to attest the fact of my failure to

secure the signature of my spouse and to attest to the
truthfulness of all the foregoing in support of the kidney
transplant subject herein.

IN WITNESS WHEREOF, I hereby affix my signature this ______ day of

_________, in Davao City.

_
Affiant

SUBSCRIBED AND SWORN TO before me this ____ day of ______, 2023 at

Davao City, affiants having executed to me his/her identification cards
NATIONAL ID - _ issued in Davao City, on ______________