AFFIDAVIT
I, xxx,
40 years old, separated, Filipino, and residing at xxx, xxx, xxx City, under
oath, depose:
1.
I am currently using
my former maiden name xxx.
2.
I was de facto
separated in 19____ from my husband xxx.
3.
In my xxx City Green Card (Hospitalization Program)
No. xxx, my former married surname xxx still appears.
4.
I am no longer
carrying the surname (xxx) of my husband.
5.
Since xxx I am have
been in a common-law marital relationship with xxx with whom I have three
children.
6.
On xxx I
delivered my third child with my common-law spouse xxx at the xxx Hospital, xxx
City.
7.
Because there is
an apparent conflict in my surname as appearing in my xxx City Green Card (Hospitalization Program) No. xxx (“xxx”) as against the current maiden surname that I am now
using (my former maiden name “xxx”), the xxx City Department of Social Services
and Development has asked me and my common-law spouse (xxx) to execute an
Affidavit to explain the said apparent conflict so that I could avail myself of
the free hospitalization benefit
under my said Green Card ID as a xxx City voter/resident.
8.
I am executing
this Affidavit to attest to the fact that the name xxx (my former maiden name)
and the name xxx (my former married name with my de facto separated spouse)
REFER TO ONE AND THE SAME PERSON, that is, myself.
9.
I am executing
this Affidavit so that I could soonest be discharged
from the xxx Hospital under the xxx City Free Hospitalization Program.
10.
I am empowering my common-law spouse xxx to
coordinate with the xxx City Department of Social Services and Development
for the processing and approval of this Affidavit and my free hospitalization
benefit.
xxx City, xxx.
X x x x
Affiant
LPC Green Card/Free
Hosp. Prog.
ID
No. xxx
SUBSCRIBED and sworn to before me in xxx City
on xxx, affiant showing her official ID Card as mentioned above.
Notary
Public
Doc. No. ___
Page No.___
Book No. ___
Series of 20xx.
