AFFIDAVIT OF GUARDIANSHIP

I, _____________________________________________, after having been sworn to in accordance with

the law, do hereby depose and say that:

1. I am of legal age, single/married and a resident of ______________________

_______________________;

2. I am the parent/court-appointed guardian of_________________________________

(name of minor);

3. I am submitting a photocopy of the Birth Certificate of the minor,

_________________________________ (if parent) or court appointment as guardian of
said minor (if judicial guardian);

4. _________________________________ (name of minor) maintained Time Deposit/ Savings/

Current Account No/s. ______________ with ___________________________ under the
account name ___________________________________________;

5. I, on behalf of _______________________________________ (name of minor) hereby lay

claim to the deposit insurance due on the account;

6. I shall be held liable to any person, that may be prejudiced by my representations, in

addition to other liabilities, civil or criminal, that may arise therefrom; hereby releasing
and discharging PDIC from any all further obligations in connection with this claim;

7. I further undertake to refund PDIC the amount paid to me including interests thereon and
indemnify PDIC, the bank and/or third parties for any loss or damages occasioned by such
payment.

I am executing this affidavit to attest to the truth of the foregoing facts.

IN WITNESS WHEREOF, I have hereunto set my mind this ___ day of ________________ at
____________________________.

_________________________________________
Parent or Judicial Guardian
SUBSCRIBED AND SWORN to before me in San Roque Northern Samar, Philippines this 2nd day of
September 2023, affiant exhibited his competent evidence of identity.

Atty. Kenneth S. Avalon

Notary Public until Dec. 31, 2023
Notarial Commission No. C-11-2023
Roll No. 84621 , IBP No. 336328
PTR No. 5435989 – July 17, 2023
MCLE: Admitted to the Bar May 02, 2023
Zone 5, San Roque Northern Samar
Doc. No. ________ ;
Page No. ________ ;
Book No. ________ ;
Series of 2023 .