AFFIDAVIT OF SUPPORT AND CONSENT

and
SPECIAL POWER OF ATTORNEY

I, _______________________________________ of legal age, Filipino single/married to

_________________________________, with residence/postal address at ________________________
___________________________________________________, hereby declare under oath: THAT –

1. I am/We are the father and/or mother of the minor(s):

Name Age

2. Said minor/s is/are applying for Philippine passport/s at the Department of Foreign Affairs;

3. I am/We are appointing ______________________________, presently residing at

_______________________________________________ to accompany my/our child/children in
applying for a passport at the ______________________________________________________;

4. I/We authorize _______________________________________, presently residing at

_________________________________________________ to secure a clearance from the Department
of Social Welfare and Development for my/our child/children, who will be travelling to
_________________________________________________ on _________________________;

5. I/We authorize ___________________________________________, presently residing at

_______________________________________________ to accompany my/our child/children during
his/her/their travel to __________________________________;

6. I am/We are willing and able to support my/our child/children during the said travel;

7. On the said travel, my/our child/children will be staying at

_______________________________________________;

8. Though the father/mother of said child/children is not here present, I am giving consent to
the above acts in as much as: (check one that applies)

[ ] said father/mother has earlier voluntarily and freely given his/her consent, with no condition
imposed whatsoever, and requested that said consent be relayed by me.
[ ] I have exclusive legal custody of minor (single parent; see attached divorce papers/death
certificate of spouse)
[ ] ____________________________________________________________

9. I/We assume responsibility for the issuance of the passport and for allowing the trip of the
said minor/s and further assume all obligations consequent thereto; and

10. I/We am/are executing this Affidavit to attest to the truth of the above statements and for
whatever legal purpose this may serve.

IN WITNESS WHEREOF, I/We have hereunto set my/our hand/s this

_________________________ in New York City, New York, United States.

_________________________ _________________________
FATHER MOTHER