passport sworn declaration by aT10o94U

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									                                                                                    LAPCG Form 01/2001
CONSULATE GENERAL OF THE PHILIPPINES }
City of Los Angeles                  } SS
State of California, U.S.A.          }


                            SWORN DECLARATION
                    TO REVERT TO THE USE OF MAIDEN NAME

       I,                                               , of legal age, Filipino citizen, married to
                                                   on                                               ,
in                                                                            , presently residing at

after having been duly sworn to in accordance with law, hereby depose and say, that:

       1.     As a consequence of my abovementioned marriage, I have used, and become known
by, my married name:                                                               .

        2.      In the exercise of the option of a married woman to revert to the use of her maiden
name pursuant to Article 370 of the New Civil code of the Philippines, as amended, and as clarified
in Opinion No. 36, Series 2000 of the Department of Justice, dated 25 April 2000, I hereby declare
that I am reverting to the use of my maiden name:
                                                                   .

       3.     I have decided to exercise this option of my own free will and volition, in good faith,
and without any purpose whatsoever that might result in confusion, damage or prejudice to the
government or the public in general.

       4.    I am executing this affidavit in connection with my application for a new passport
under my maiden name with the Philippine Consulate General in Los Angeles, California.

       IN WITNESS WHEREOF, I hereby affix my signature this                day of
in Los Angeles, California, U.S.A.




                                                                        Affiant

       SUBSCRIBED and SWORN to before me this ______ day of ____________________ in
Los Angeles, California, U.S.A., with the affiant exhibiting to me her photo-document (passport,
green card, driver’s license) No. ______________________ issued on ______________________
at                                          .




                                                                Administering Officer

Fee Paid :
O.R. No. :
Service No.:
Doc. No. :
Page No. :
Series of

								
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