REPUBLIC OF THE PHILIPPINES)

Caloocan City )S.S.

Sworn Affidavit

I, ______________________________, of legal age, Filipino, ____________, and with

residence at ________________________________,______________________ after having
been duly sworn to in accordance with law, hereby depose and state that:

1. I am the _________________ of the following child/children;

NAME AGE BIRTHDATE

a. ______________________________ ____ _________________________
b. ______________________________ ____ _________________________
c. ______________________________ ____ _________________________
d. ______________________________ ____ _________________________
e. ______________________________ ____ _________________________

2. The said children are minors and solely dependent on me for support;

3. I am a solo parent and I am not cohabiting with any partner or co-parent and I have the
sole parental care and support of my above-mentioned child/children;

4. I executed this affidavit to attest foregoing facts and for whatever legal services purposes
this may serve.

In witness whereof, I have hereunto set my hands this _____ day of ___________ 2022
in Caloocan City.

________________________
Affiant

Subscribed and sworn to before me this ____ day of _________ 2022 in the Caloocan
City. Affiant exhibiting to me his/her
____________________________________________________.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2022.