REPUBLIC OF THE PHILIPPINES )

__________________________ ) S.S.

AFFIDAVIT OF SOLO PARENT

I, _____________, a Filipino citizen, of legal age, residing at

______________, Pagbilao,Quezon, after being sworn to in accordance with
law, depose and say that:

1. I am a solo parent who is not married;

2. During our relationship, we were blessed with______ child;

3. I was left alone with the responsibility of parenthood due to financial

incapacity of the father and lack of financial support to the child for 3
consecutive years.

4. Assumes the responsibility of head of family as a result of the

abandonment or absence of the father.

5. Parent left solo or alone with the responsibility of parenthood due to

abandonment of spouse for at least one year;

6. I am executing this affidavit to attest to the foregoing facts and for the
purpose of securing a Solo Parent ID and to receive the benefits
under the Solo Parents’ Welfare Act of 2000.

IN WITNESS WHEREOF, I have hereunto set my hand this ___ day of

January, year 2023 in Municipality of Pagbilao Quezon, Province.

____________________

Affiant

SUBSCRIBED AND SWORN TO before me this ______ day of

January in Municipality of Pagbilao, Quezon Province, Philippines,the affiant
exhibiting to me her competent evidence of identity by way
_________________ with both her picture and signature appearing therein.