REPUBLIC OF THE PHILIPPINES ) PROVINCE OF ________________________ ) MUNICIPALITY/CITY OF

________________ ) AFFIDAVIT OF GUARDIANSHIP I, _____________(name of

guardian)____________________________________, of legal age, _____(civil status)________ and
presently residing at _________________________________, after being duly sworn to in accordance
with law, depose and state: 1. That I am the ___________________ (relationship)_____________ of the
minor named below who was granted scholarship for Grades 7 to 12 at Philippine Science High School -
________________ Campus: NAME OF MINOR : DATE OF BIRTH : PLACE OF BIRTH : 2. That the parents
of the above-named child _________________state circumstance why parents cannot sign/appear at
PSHS__________________________________________; 3. That I am the guardian of the above-named
minor since _____________year_____; 4. That the said minor is under my care and custody; 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 him to commit offenses
against the law. 6. That I shall fully commit to guide and support the above-named minor in his studies
at PSHS-________CAMPUS in accordance to its school rules and regulations. Done this
______date_______________ at __________________________. _________________________ Name
and Signature of Affiant SUBCRIBED AND SWORN to before me, this _______________ at
______________________, affiant exhibiting to me his/her valid government
ID____________________, issued on __________________ at _________________________. NOTARY
PUBLIC Doc. No. __________ Page No.__________ Book No.__________ Series of __________.