AFFIDAVIT OF SUPPORT AND PARENTAL CONSENT

WITH SPECIAL POWER OF ATTORNEY

FOREIGN SERVICE OF THE PHILIPPINES )

CONSULATE GENERAL OF THE REPUBLIC OF THE PHILIPPINES ) SS.
_______________________________________________________ )

I, ________________(name of affiant)____________, Filipino, of legal age, [single]/[married to

_________(name of spouse)_________], and a resident of ___________________(address of
affiant)_______________, after having been duly sworn in accordance with law, hereby depose
and state:

1. That I am the [father]/[mother] of the minor(s):

LIST OF MINORS:

Name Date of Birth and Age

__________________________________ ________________________
__________________________________ ________________________
__________________________________ ________________________
__________________________________ ________________________
__________________________________ ________________________

2. That the minor(s) [is]/[are] applying for Philippine passport(s) at the Department of
Foreign Affairs, in order to join me here in ___________(foreign country)____________;

3. That I am willing and able to support him/her/them while being here;

4. That [Mr]/[Mrs]/[Miss]_______________________________________________,
presently residing at , ___________________________________ will apply for my
child/children’s passport in the Philippines;

5. That [Mr]/[Mrs]/[Miss] _________________________________________ will

accompany my child/children during their travel from the Philippines to the
______________(foreign country)______________;

6. That I authorize [Mr]/[Mrs]/[Miss] _________________________________________,

presently residing at _________________________________________ to secure a
clearance from the Department of Social Welfare and Development for my
unaccompanied minor [child]/[children], who will be traveling to
______________________ on _______________________________;

7. That my [child]/[children] will be staying with me at

______________________________;

8. That though the minor(s)’ [father]/[mother] is not here present, I am giving consent to
said minor(s)’s travel in as much as: (check one that applies)

[__] said [father]/[mother] has earlier voluntarily and freely given [his]/[her]
consent, with no condition imposed whatsover, and requested that said consent
be relayed to me.

[__] I have exclusive legal custody of minor (see attached [divorce decree]/[death
certificate]/[etc.])

[__] _________________________________________________________

9. That I assume responsibility for the issuance of the passport and for allowing the trip of
said minor(s) and further assume any and all obligations consequent thereto; and

10. That I am are executing this Affidavit to attest to the truth of the above statement in
connection with said minor’s application for a Philippine passport.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____th day of ____________
20___ at ____________, Philippines.
_______________(signature)_______________
(Printed Name)

SUBSCRIBED AND SWORN TO BEFORE ME, a notary public in and for

_________(City/Province)____________ this ____th day of ____________ 20___. Affiant
personally came and appeared with _____________(Competent Evidence of Identity)______
issued by the _________(Government Agency)______ on ___(date)__ at
________(place)_________, bearing his photograph and signature, known to me as the same
person who personally signed the foregoing instrument before me and avowed under penalty of
law to the whole truth of the contents of said instrument.

Atty ___________________________________________
Notary Public
Doc. No. ____ Commission Serial No. ____________________________
Page No. ____ Notary Public for _______(Province/City)______________
Book No. ____ Until December 31, 20__
Series of 20__ Office: ______________(address)____________________
Roll No. __________
IBP Lifetime Roll No. _________; __/__/__ ; _(Province)_
PTR No. _________ ; __/__/__ ; _(Province)_
MCLE Compliance Cert. No. __________; __/__/__

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