REPUBLIC OF THE PHILIPPINES )

Tagum City, Davao del Norte ) S.S.

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AFFIDAVIT OF GUARDIANSHIP
I, ________________, of legal age, Filipino, single, and a resident of
Tagum City, after having been duly sworn to in accordance with law, do hereby
depose and say:

1. That I am the same and identical person who cause the execution of
this affidavit;

2. I am the cousin of _______________, eight months old who was

born on ______________;

3. He is the illegitimate child of my aunt, __________________;

4. Presently, ________________ is under my care and custody

considering that his mother is presently working in the distant place,
thus, I am the one providing for his well-being, safety and medical
needs;

5. Thus, in the absence of his parent, I further extend my standing as

the legal guardian and representative of ________________ with
regard to his application for membership with PhilHealth and all the
matters needed for said application of membership;

6. That I am executing this affidavit in my capacity as his guardian, to

attest to the truth of the foregoing circumstances and for whatever
legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this _____ day

of ____________ at Tagum City, Davao del Norte.

___________________
Affiant

SUBSCRIBED AND SWORN to before me this ________ day of

_______________ at Tagum City, Davao del Norte. Affiant exhibited to me
her PRC I.D. No. _________________.