REPUBLIC OF THE PHILIPPINES)

) Ss.

AFFIDAVIT OF UNDERTAKING AS CUSTODIAN

I, , Filipino, of legal age, single/married/widow/widower, and

a resident of , after having been duly sworn to in
accordance with law, depose and state, that:

1. I am the incumbent Punong Barangay of Barangay ,

City;

2. is one of the residents of our barangay;

3. I was informed that has applied for probation having been

convicted for the crime of by the Trial Court of

, Branch _, and docketed as Criminal Case No. ;

4. I was further made to understand that desires to be released on

recognizance pending the resolution of her application for probation, and needs a
custodian for this purpose;

5. I hereby agree to be the said custodian of and undertakes to

bring him to court whenever required;

6. I am executing this affidavit to apprise all those concerned of foregoing facts and
for whatever other legal purpose it may serve.

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

, at , Philippines.
 Affiant

SUBSCRIBED AND SWORN to before me this day of

, at
, Philippines. The identity of the affiant is established by his
Philippine Passport No. _, issued on_.

NAME OF PUBLIC ATTORNEY

Public
Attorney

(Pursua
nt to
R.A.
9406)