(Affidavit 

of Intent and Consent to Adoption of Child)

Republic of the Philippines)
Province of________________)S.S.
City/Municipality of ____________)
x-- - - - - - - - - - - - - - - - - - - x

JOINT AFFIDAVIT OF INTENT AND CONSENT

We,___________and__________,both Filipinos, of legal age, married and presently residing
at____________, Philippines, having been duly sworn in accordance with law, hereby depose
and state:

1.That we are the legitimate parents of ____________who was born

on____________in___________ Philippines.

2.That we have not, at any time abandoned said minor child.

3.That we are unable to support said child and that believing that it would be for (his/her)own
interest and benefit, we, hereby signify our written intent, freely and voluntarily to have
our(son/daughter) ____________be adopted.
4.That we also signify our written consent, freely, willingly and voluntarily to have our
son/daughter)____________be legally adopted by the
spouses_________and___________of___________, Philippines in accordance with law.
5.That we are ready and willing, freely and voluntarily to abdicate our parental authority over
said child in favor of the spouses____________and_____________, who are ____and
_____years of age, respectively, and who are both possessed of the necessary civil and legal
rights as well as the financial capacity to raise, rear and support said child, after the adoption
proceeding had been instituted and an order of adoption be issued.
6.That we execute this affidavit to declare our intention and consent to the adoption of our
(son/daughter)_________as well as to the truth of the foregoing facts.
IN WITNESS WHEREOF, we have hereunto set our hands
this____________at"_____________, Philippines.
Affiant Affiant

(JURAT)