REPUBLIC OF THE PHILIPPINES )

CITY OF MANDAUE ) S.S.

AFFIDAVIT OF GUARDIANSHIP

I, _________________________, of legal age, widow, Filipino and residing

at _____________________________ after being duly sworn to, in
accordance with law, do hereby depose and say:

1. That I am the mother of _______________________, a minor, who

has an interest in the proceeds of insurance on the life of the late
_______________________, my deceased husband, as well as the
GSIS/SSS Fund and Pag-Ibig Fund benefits of the said deceased;

2. That I am the guardian of the above-named minor;

3. That the said minor is under my care and custody;

4. That I am competent to receive on behalf of the said minor the

proceeds of insurance of the deceased, as well as the latter’s benefits
under the GSIS/SSS Fund and Pag-Ibig Fund and any amount due her;

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 her to commit
offenses against the law.

Done this _____ day of _______________________ at

_______________________.

Witness: _______________________ _______________________

Affiant

CORROBORATION

We, ________________ and ________________________,

both of legal age, Filipinos and residents of ________________________
and ___________________, respectively, and _____________________
(relationship) and ____________________, respectively, hereby confirm
the foregoing statements of _______________________, to be true and
correct.

_______________________ _______________________
Affiant Affiant

SUBCRIBED AND SWORN to before me this _____day of

_______________________ at _______________________. Affiants
exhibited to me their respective Identification Cards/Residence Certificates
as follows: Name of Affiant CTC/ID No. Issued at Issued on / Expiry Doc.
No. _____; Page No. _____; Book No. _____; Series of _____.