Republic of the Philippines)

) s.s.
x--------------------------------x

AFFIDAVIT OF CONSENT TO ADOPTION

I, ___________________________, Filipino, of legal age, single,

with residence and postal address at ______________________________,
after having been duly sworn in accordance with law, hereby depose and
state:

1. I am the biological mother of _________________________

who was born on ______________ in ___________ City, Philippines.

2. For the best interest of my son, ________________, I am

voluntarily giving my consent to his adoption by
____________________, and I am voluntarily turning over and
surrendering full custody of my child to her.

3. I have decided to give my consent to my son’s adoption since I

could not raise him alone as I am a single mother with no financial means
to support him.

4. This affidavit has been made and executed to attest to the truth
of the foregoing and for all legal intents and purposes.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

_______________ at _______________ City, Philippines.

_______________________

SUBSCRIBED AND SWORN to before me this ___________________

at ______________ City, Philippines, affiant personally came and exhibited
to me her _______________________ as competent proof of her identity.

Doc. No. ____;

Page No ____;
Book No. ____;
Series of 201_.