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 __________.

PSHS-00-F-REG-04-Rev0-12/05/16