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
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.
Doc. No. ___
Book No. ___
Series of 20xx.