AFFIDAVIT OF UNDERTAKING

I/We, _____________________________________________,
Ray Kristoffer Nosis Refuerzo of legal age, with residence and
postal address at ____________________________________________________,
36 Digos Street Luzviminda Village Batasan Hills Quezon City after having
been duly sworn to in accordance with the law hereby depose and state that:

1. I am the companion of minor ______________________________________

Sean Neijhelle Delos Santos Refuerzo who
together with me will travel to ___________________ on ____________ for the
Japan November 17, 2023
purpose of _______________________________________.
Vacation/Tourism

Son
2. That the said minor is the _________________ of _______________________________
John Vincent Refuerzo / Jobelle Delos Santos
who gave their full consent and permission to me as companion of their minor
daughter/son;

3. I am the ___________________________
Uncle of _________________________________
Sean Neijhelle Delos Santos Refuerzo

4. I hereby undertake and affirm that, I, together with the minor/child will return to the
Philippines as soon as we finish the duration of our __________________
Vacation/Tourism in
____________________
Japan and promise to inform the Minors Traveling Abroad Section,
DSWD X Office 5 days upon arrival:

5. I assume full responsibility over the minor’s safety and welfare during the entire
duration of our travel and stay at ___________________________________________
Imano Tokyo Hotel, 5 Chome-12-2 Shinjuku, Shinjuku City, Tokyo
and hold the staff, officers and or any employee of DSWD X free and harmless from
all and any liability arising from the travel of the said minor;

6. I executed this affidavit to attest to the truth of the foregoing facts and for whatever
legal purpose this may serve.

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

__________, 2023 at______________________________

________________________________
Ray Kristoffer Nosis Refuerzo
AFFIANT

SUBSCRIBED AND SWORN TO before me this _________day of _____________, 2022 at

_____________________________ affiant exhibited to me
her/his__________________________ No ______________, issued on ______________at
_______________ thereon as proof of her identity.

Doc. No._________
Page No. _________
Book No. _________
Series of _________-