REPUBLIC OF THE PHILIPPINES )

CITY OF ILAGAN ) S.S.

PROVINCE OF ISABELA )
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AFFIDAVIT

I, KURT VINCENT DELOS SANTOS, Filipino, of legal age, single,

and with residence at Purok 2, Bliss Village, City of Ilagan, Isabela, after
being duly sworn to in accordance with law, hereby depose and state:

1. That I am a student of Isabela State University – Ilagan Campus;

2. That the name appearing in my academic records is KURT

VINCENT D. SANTILLAN;

3. That the name appearing in my Certificate of Live Birth is KURT

VINCENT DELOS SANTOS appended herein as Annex “A”;

4. That I am changing the name in my academic records from KURT

VINCENT D. SANTILLAN to KURT VINCENT DELOS SANTOS to
conform with the name appearing in my Certificate of Live Birth;

5. That I have executed this affidavit to affirm the veracity of the

foregoing statements and admit under oath of the foregoing facts for
whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

March 20, 2024, at the City of Ilagan, Isabela.

KURT VINCENT DELOS SANTOS

Affiant

SUBSCRIBED and SWORN to before me this March 20, 2024 at the

City of Ilagan, Isabela by affiant who exhibited to me his Philhealth ID No.
06-025443522-0.

ATTY. MARY GRACE M. CAMMAYO-

GAOIRAN
Public Attorney II
Administering Oath
Pursuant to RA 9406