Republic of the Philippines )

City of ______ ) S.S.

x--------------------------x

AFFIDAVIT OF GUARDIANSHIP

I, _________________, of legal age, single/married/widow, Filipino citizen, and

presently residing at _____________________, after having been duly sworn to in
accordance with law, do herebydepose and say:

1. That I am the ___(state relationship)__ and guardian of the following minor/s who has /
have an interest in the _______________ of the late _________________________
payable by ________________;

Full Name of Minor/s Date of Birth Age

_______________ _________ ______
_______________ _________ ______
_______________ _________ ______

2. That the above mentioned minor/s is/are under my care and custody;

3. That I am competent to receive in behalf of the said minor/s any amount/s due him/them;
and

4. That I am not an imbecile, insane, a vagrant or a vicious person or a habitual drunkard or

a habitualcriminal, and have not abandoned, neglected or refused to support said minor/s or
caused him/them to commit offenses against the law.

5. That I am executing this affidavit to attest to the truth of all the foregoing statements and
for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ day of _______
2014 at ______________, Philippines.

________________
Affiant

SUBSCRIBED AND SWORN to before me this ____ day of ______ 2014 in

_________, Philippines, affiant exhibiting to me his/her competent evidence of identity by way
of _______________ issued at ___________ on ________________.

Doc No. : _____

Page No.: ______
Book No.: ______
Series of 2014 Notary Public