Republic of the Philippines )

Roxas City, Capiz) S.S.

x--------------------------x

AFFIDAVIT OF GUARDIANSHIP

I, _________________, of legal age, single/married/widow, Filipino citizen, and presently

residing at _____________________, after having been duly sworn to in accordance with law, do
hereby depose and say:

1. That I am the ___(state relationship)__ and guardian of the following minor/s who has / have an
interest in the _______________ of the late _________________________ payable by
________________;

Full Name of Minor/s Date of Birth Age

_______________ _________ ______
_______________ _________ ______
_______________ _________ ______

2. That the above mentioned minor/s is/are under my care and custody;

3. That I am competent to receive in behalf of the said minor/s any amount/s due him/them; and

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

habitual criminal, and have not abandoned, neglected or refused to support said minor/s or caused
him/them to commit offenses against the law.

5. That I am executing this affidavit to attest to the truth of all the foregoing statements and for
whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ day of _______ 2014 at
______________, Philippines.

________________
Affiant

SUBSCRIBED AND SWORN to before me this ____ day of ______ 2014 in _________,
Philippines, affiant exhibiting to me his/her competent evidence of identity by way of
_______________ issued at ___________ on ________________.

Doc No. : _____

Page No.: ______
Book No.: ______
Series of 2023