You are on page 1of 1

REPUBLIC OF THE PHILIPPINES)

PROVINCE OF EASTERN SAMAR )S.S.


MUNICIPALITY OF BALANGIGA )
AFFIDAVIT OF CONSENT TO TRAVEL
I, THELMA AUCINA ALGARIO, of legal age, Filipino, single and
presently residing at Brgy. Bitaog, Lawaan, E. Samar after having been duly
sworn to in accordance with law, depose and state:
1. That I am the biological parent of RODELL AUCINA. ALGARIO who was
born on March 8, 2009 in Brgy. Bitaog, Lawaan, E. Samar.
2. That said child will travel to PENSACOLA FLORIDA 32506, UNITED STATES OF
AMERICA for the following reason/s: to have his right ear check by an ear
specialist and to have a tour and vacation experience in the United States of
America;
3. That said child will be leaving sometime on December this year 2016 and will
stay in the said country for a period of one (1) month and will be taken
cared of by SUSANA BOSARGE the guardian;
4. That I am giving my full consent for the minor child to travel abroad to be
accompanied by SUSANA BOSARGE;
5. That I am executing this affidavit in connection with my child
application for a passport at the Department of Foreign Affairs and/or travel
clearance from the Department of Social Welfare and Development for his
travel abroad.
IN WITNESS WHEREOF, I have hereunto set my
this ___________________ in _______________, Philippines.

hand

THELMA A. ALGARIO
Affiant
SUBCRIBED
AND
SWORN
to before
me
this ___________________ in Balangiga, E. Samar, Philippines, affiant
exhibiting
to
me
her
valid
proof
of
identification____________________________.

Doc. No. _____;


Page No. _____;
Book No. IV;
Series of 2016.

You might also like