REPUBLIC OF THE PHILIPPINES)

PROVINCE OF A ) S.S.
MUNICIPALITY OF B )

AFFIDAVIT OF SUPPORT AND CONSENT TO TRAVEL

I, C, of legal age, married to D, a Filipino citizen, and a resident of Barangay N, B, A, after having
been duly sworn to in accordance with law, hereby depose and state:

1. That I am the mother of E;

2. That my child will travel to G for vacation;

3. That the mentioned child will be leaving on xx/xx/xxxx and will stay on the said country
for a period of zzz days;

4. That I am giving my full consent for the minor child to travel abroad to be accompanied by
H and I;

5. That I personally guarantee the financial support of the child in the course of his travel and
stay outside the Philippines and further guarantee that he will not in any manner become
public ward of any authority of any country he may happen to pass en route to his
destination;

6. That this affidavit was executed for the purpose of attesting to the truth of the foregoing
facts and for whatever legal purposes and intents this may serve.

Signed on the date and at the place indicated below.

C
Affiant
ID No. XXXXX
Issued on XXXXX
Valid until XXXXX
Issued at XXXXX

SUBSCRIBED AND SWORN TO before me on the date and at the place indicated below. The affiant
exhibited to me her competent evidence of identity as indicated above.

Signed this xx day of xxxx at B, A, Philippines.

WITNESS MY HAND AND SEAL

Doc. No. _________;

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