REPUBLIC OF THE PHILIPPINES )

City of Valenzuela ) SS.

AFFIDAVIT
(RE: GUARDIANSHIP OF INCOMPETENT)

I, ________, of legal age, married, Filipino, and residing at

_______________________________________________, after being duly sworn
according to law, depose and say:

1. That I am the legitimate spouse of the incompetent _____________ who has an

interest in the proceeds of claim for disability/sickness benefit payable by the
Social Security System;

2. That the above-mentioned incompetent is under my care and custody and

presently confined at ______________;

3. That I am competent to receive in behalf of the said incompetent the amount(s)

due him as disability/sickness benefit of the subject member of the social
Security System;

4. That I am not an imbecile, insane, vagrant or vicious person or habitual

drunkard or habitual criminal, and have not abandoned, neglected or refused to
support said incompetent or caused him to commit offense against the law;

5. That the amount due the incompetent named above does not exceed
___________________ PESOS (P________).

_______________________________
Affiant

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CORROBORATION

(To be accomplished by two disinterested persons who are prominent in the community)

We, ________, of legal age, married, Filipino, and residing at

_______________________________________________, and _____________
________, of legal age, married, Filipino, and residing at
_______________________________________________, hereby confirm the foregoing
statement Mr./Mrs. ___________________.

SUBSCRIBED AND SWORN to before me this ____ th day of ______, 20__ in

________________, Philippines, affiant exhibited to me their Community Tax Certificate
as follows:

Name C.T.C. No. Date and Place Of Issue

Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 200_.