Republic of the Philippines)

Province of Davao del Norte) S.S.

CITY OF TAGUM……………) S.S.
x------------------------------x

AFFIDAVIT OF INTENT AND CONSENT TO ADOPTION

I, HAROLD VELASQUEZ, of legal age, Filipino citizen, single and a resident of
Metro Manila, under oath, do hereby jointly declare:

1. I am the biological father of BELLA YRRAH DOLOJAN VELASQUEZ,

who was born out of wedlock on February 21, 2011, at Bishop Joseph
Regan Memorial Hospital, Tagum City;

2. I have allowed BERSEE PAULA DOLOJAN-AVILA, the mother of the said

minor child to have sole parental custody of our daughter since 2011;

3. I was unable to provide full support for the said child and believing that
it would be for her own interest and benefit, I, hereby signify my written
intent, freely and voluntarily to have our child BELLA YRRAH DOLOJAN
VELASQUEZ be adopted;

4. Her mother BERSEE PAULA DOLOJAN-AVILA and her husband-

ARNEL AVILA have manifested to me their intention of adopting our
above-named child;

5. Believing on the sincerity of the above-named Avila spouses, and on a

brighter future that they can give to our above-named child, I further
signify my written consent, freely, willingly, and voluntarily to have our
child BELLA YRRAH DOLOJAN VELASQUEZ be legally adopted by Avila
spouses;

6. I am executing this Affidavit to attest to the truth of the foregoing and to

apprise the proper authorities/agencies, especially the DSWD and the
court, as to the facts aforementioned.

IN TRUTH WHEREOF, I have hereunto set my hand this ___ day of September
2019 in Tagum City, Davao del Norte.

HAROLD VELASQUEZ
Affiant
ID No. ______________
Issued by ___________

SUBSCRIBED AND SWORN to before me this ____ day of September 2019, in

Tagum City, Affiant having exhibited to me his respective document of identity
as above-noted.

Doc. No. _________;

Page No. _________;
Book No._________;
Series of 2019.