Republic of the Philippines)

________________________) S.S.

AFFIDAVIT

I, _________________________, Filipino, of legal age, with residence address at

_________________________________________________________________, after having
been duly sworn in accordance with law, hereby depose and say that:

1. I am the father and legal guardian (hereinafter, “Legal Guardian”) of the minor/s,
_________________________________________, whose date/s of birth is/are
_________________________________________ (hereinafter, the “Minor/s”).

2. There is no other judicially appointed guardian over the person or property of the
Minor/s.

3. Minor/s has/have not been adopted by another person.

4. Legal Guardian has not ever been judicially declared as having abandoned Minor/s.

5. Legal Guardian has not ever been judicially declared as absent or incapacitated to
exercise parental authority over the person/s and/or property/ies of Minor/s.

6. Legal Guardian has never been divested of parental authority over the person/s and/or
property/ies of Minor/s.

7. Legal Guardian has never been convicted of any crime which carries with it the penalty
of civil interdiction.

8. Legal Guardian has not excluded any other legal guardian of the person or property of
the Minor/s.

9. I hereby hold Sun Life of Canada (Phils.), Inc., its agents, employees, and all those
acting on its behalf, free and harmless from, and shall indemnify them for, any and all
liability whatsoever that may arise from the foregoing representations.

I execute this affidavit to attest to the truth of the foregoing and to be entitled to receive the
proceeds of Insurance Policy No. ________________ on behalf of Minor/s, the beneficiary/ies
named on said policy.

Affiant further sayeth naught.

____________________
Affiant

SUBSCRIBED AND SWORN to before me this _____ day of ______________, with affiant
exhibiting his Government-issued ID [Passport/Driver’s License/SSS/TIN No.] ______________
issued at __________________________ on ________________ and his Government-issued ID
[Passport/Driver’s License/SSS/TIN No.] ______________ issued at
__________________________ on ________________..

Doc. No.: Notary Public

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Book No.:
Series of 20__