Republic of the Philippines }

City of ____ S.S.}

AFFIDAVIT OF NON-COHABITTION

I, MYRNA [MIDDLE AND LAST NAME], Filipino, of legal age, and residing in [PRINCIPAL
ADDRESS], do hereby depose and state that:

1. That I am co-habiting with a certain [NAME OF CO-HABITED SPOUSE] for a period of

[DURATION

2.That on [DATE], 2 years from today, the named [NAME OF CO-HABITED SPOUSE]
abandoned us and has not provided any financial support ever since.

3. That I am executing this affidavit for purposes of my application for Solo Parent ID with
DSWD

MYRNA [MIDDLE AND LAST NAME]

Signed by Notary Public

Affiant

SUBSCRIBED and SWORN before me, on [DATE OF NOTARIAL ACT] in the City of
[NAME OF CITY], affiant exhibited to me her [COMPETENT EVIDENCE OF IDENTITY].

ELLERTON KNOLL M. NIVERA

NOTARY PUBLIC

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