Republic of the Philippines )

Municipality/City of ________________ ) S. S.
Province of ____________ )

AFFIDAVIT

I, ________________________________ after having been duly sworn to in accordance with law,

hereby depose and say that I:

1. Am a Filipino, of legal age and resident of _________________________________________;

2. I am the mother of ___________________________ and ___________________________ who
were born on ___________________ and ____________________ at __________________________,
respectively;
3. That their biological father is _______________________________;
4. I am now separated with my husband for almost _________ years since ____________,
he abandoned us without providing any financial support for our children;
5. Through this Affidavit, I hereby declare under oath that I am the solo parent and
sole guardian to my children and the one taking custody and providing support
for them; and
6. That I am not cohabiting with a partner or co-parent.

I am executing this affidavit to attest to the truth and veracity of the foregoing
statements.

IN WITNESS WHEREOF, I have set my hand this ______ day of ____________________ at

________________________________.

________________________________
Name & Signature of Affiant
ID/ No. _________________________
Issuance/Validity Date _____________

SUBSCRIBED AND SWORN to before me in the Municipality/City of __________________ this

_______ day of _____________________ by the affiant, who has satisfactorily proven her identity
to me that she is the same person who personally signed the foregoing affidavit before
me and acknowledged that she executed the same.

Notary Public
Doc. No. ________ ;
Page No. ________ ;
Book No. ________ ;

Series of ________ .