REPUBLIC OF THE PHILIPPINES)

Caloocan City ) S.S.

AFFIDAVIT

I, ____________________________, of legal age, Filipino, _________, and with residence

address at _____________________________________________, after having been duly sworn to in
accordance with law, hereby depose and state that:

1. I am an incumbent/elected ________________ of Barangay _______, District ___, Caloocan

City;

2. Ms./Mr. ____________________ is applying for solo parents Identification card before the
Caloocan City Solo Parents Office for the benefits of R.A. 8972 as amended otherwise
known as the “Solo Parents Welfare Act”;

3. Ms./Mr. ____________________ is a legitimate residence of Barangay _____ since _____ or

for ___ years with present address at _______________________________;

4. ____________________ is the _______________ of the following minor/children:

Name Age Birthdate

a. ____________________________ ___ _________________
b. ____________________________ ___ _________________
c. ____________________________ ___ _________________
d. ____________________________ ___ _________________
e. ____________________________ ___ _________________

5. I am executing this affidavit to attest the truth of the foregoing and to confirm that
__________________________ is a qualified solo parent under the category _____ as
provided under R.A. 11861 and he/she is neither cohabiting any person nor has a co-parent
and the above-mentioned minor children is under his/her sole parental care and support;

IN WITNESS WHEREOF, I have hereunto set my hands this ____ day of ___________ 2022 in
Caloocan City, Metro Manila.

________________________
Affiant

SUBSCRIBED AND SWORN to me before this _____ day of __________ 2022 in Caloocan
City, Metro Manila. Affiant exhibiting to me his/her _____________________________________.

Doc no.: _______;

Page no.: _______;
Book no.: ______:
Series of 2022.