REPUBLIC OF THE PHILIPPINES )

CITY OF MANDAUE ) S.S.

AFFIDAVIT OF GUARDIANSHIP
I, _________________________, of legal age, widow, Filipino and residing at
_____________________________ after being duly sworn to, in accordance with law, do
hereby depose and say:

1. That I am the mother of _______________________, a minor, who has an

interest in the proceeds of insurance on the life of the late
_______________________, my deceased husband, as well as the GSIS/SSS
Fund and Pag-Ibig Fund benefits of the said deceased;

2. That I am the guardian of the above-named minor;

3. That the said minor is under my care and custody;

4. That I am competent to receive on behalf of the said minor the proceeds of

insurance of the deceased, as well as the latter’s benefits under the GSIS/SSS
Fund and Pag-Ibig Fund and any amount due her;

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

drunkard or a habitual criminal, and have not abandoned, neglected or refused to
support said minor or caused her to commit offenses against the law.

Done this _____ day of _______________________ at

_______________________.

Witness: _______________________ _______________________

Affiant

CORROBORATION

We, _____________________________ and _____________________________,

both of legal age, Filipinos and residents of _______________________________ and
_________________________________, respectively, and _____________________
(relationship) and ____________________, respectively, hereby confirm the foregoing
statements of _______________________, to be true and correct.

_______________________ _______________________
Affiant Affiant

SUBCRIBED AND SWORN to before me this _____day of

_______________________ at _______________________. Affiants exhibited to me their
respective Identification Cards/Residence Certificates as follows:

Name of Affiant CTC/ID No. Issued at Issued on / Expiry

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of _____.