REPUBLIC OF THE PHILIPPINES)

)S.S.
..)

AFFIDAVIT OF GUARDIANSHIP
I,____________________of legal age,single/married/widow/widower,and residing
at___________________________after being duly sworn according to law depose and
say:
1. That I am the ____________of the minor/s mentioned below who has/have an
interest in the proceeds of the insurance of the late
_________________________payable by the Department of the Interior and Local
Goverment.

2.
3.
4.

5.

Name of Minor/s
Age
____________________
______________________
____________________
______________________
____________________
______________________
That the above mentioned minor/s s/are under my care and custody;
That I am competent to receive in behalf of the said minor/s the amount due
him/them in the proceeds of insurance of insured;
That I am not an imbecile,insane,vagrant or vicious person,or a habitual
drunkard or a habitual criminal,and has not abandoned,neglected or refused
to support said minor/s,or caused him/her to commit offenses against law;
That the minor/s named above does/do not own any property the aggregate
amount of which exceeds who thousand pesos(php2,000.00).

__________________________
AFFIANT
CTC
No._________________
Issued
on _______________
Issued
at ________________
CORROBORATION
We,________________________________and _____________________________,
_____________________________________of _____________________________,both of legal
age,single/married hereby confirm the
foregoing
statements
of
Mr/Mrs.____________________________________to be true and correct
________________________
__________________________
(Affiant)
(Affiant)
________________________
__________________________
(Official Title)
(Official Title)
Subscribed and sworn o before this_____day of______________in the
city/municipality of____________,province of ___________,Philippines.
Affiants exhibiting to me, respectively, their Residence Tax Certificates.
No.___________________
Issued at ________________on_______________________
No.___________________
Issued at________________on_______________________
No.___________________ Issued at ________________on_______________________
Doc.No.________

Page No._______
Book No.______
Series of_______