Republic of the Philippines)

Province of Masbate )
City of Masbate )
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AFFIDAVIT OF GUARDIANSHIP

I, MARICAR M. BALAT, Filipino, of legal age, and a resident of Market Site,

Masbate City, after having been duly sworn to in accordance with law, hereby
depose and state:

1. That I am the mother of LEI ANDREA B. PINAT, 9 years old; LIAM KENT
B. PINAT, 3 years old; LIAM KYLE B. PINAT, 2 years old and LIAM KIRK
B. PINAT, 2 years old;
2. That all the above-named children are under my care and custody and
dependent upon me for support morally and financially;
3. That however, my son in the name of LIAM KEITH B. PINAT, 7 years old,
is currently under the custody of his grandmother, ELEONOR D. PINAT,
as I entrusted the custody of the former to the latter when I got sick, and
said child continues to be under the care and custody of his grandmother;
4. That their father, PO2 GERSOM DADANG PINAT, JR., my common-law
husband died on September 8, 2016 at Mandaon, Masbate
5. That he has an insurance policy in Public Safety Mutual Benefit Fund,
Inc.(PSMBFI) which has its principal office in 318-320 Santolan Rd., cor.
1st and 2nd West Crame Streets, Brgy. West Crame, San Juan, Metro
Manila;
6. That I will be claiming the benefits under said policy in behalf of my
minor children;
7. That I shall be held liable to any person, that may be prejudiced by my
representations, in addition to other liabilities, civil or criminal, that may
arise therefrom; hereby releasing and discharging the Public Safety
Mutual Benefit Fund, Inc.(PSMBFI) from any all further obligations in
connection with this claim;
8. That I further undertake to refund Public Safety Mutual Benefit Fund,
Inc.(PSMBFI) the amount paid to me including interests thereon and
indemnify PDIC, the bank and/or third parties for any loss or damages
occasioned by such payment.
9. That I am executing this affidavit to attest to the truth of the foregoing
facts.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 18th day

of July, 2017 at Masbate City, Philippines.

MARICAR M. BALAT

SUBSCRIBED AND SWORN TO before me this 18th day of July, 2017 at

Masbate City, Philippines.

Doc No. ____;

Page No. ____;
Book No. ____:
Series of 2017.