REPUBLIC OF THE PHILIPPINES )

PROVINCE OF CAPIZ ) S.S

MUNICIPALITY OF MAMBUSAO )
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AFFIDAVIT OF GUARDIANSHIP

I, MAY RUBY M. GERSON, of legal age, Filipino, married to JORLEY O.

GERSON, and a resident of Salcedo, Dumarao, Capiz, Philippines, after having been
sworn to in accordance with law, hereby depose and state that:

1. I am the biological mother/parent of the minor child JERINCE M. GERSON;

2. That the above named minor is under my parental authority, care and custody;

3. That I am competent to apply for and/or receive any assistance from the
Philhealth in behalf of my minor child who is currently confined at Dao Municipal
Hospital;

4. That I am not an imbecile, vagrant, or vicious person, or a habitual drunkard or a

criminal, and has not abandoned, neglected, or refused to support my minor child
or cause her to commit any offense against the law; and

5. I am executing this affidavit to attest to the truth of the foregoing facts and for
whatever legal purpose the same may serve best.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

____________________ at Mambusao, Capiz, Philippines.

MAY RUBY M. GERSON

Affiant
National I.D. No. 4502-9140-1908-5362

SUBSCRIBED AND SWORN to before me this ____________________ at

Mambusao, Capiz, Philippines, by the affiant after exhibiting to me her competent proof
of identity written below her name.