REPUBLIC OF THE PHILIPPINES)

Province of Camarines Norte ) S.S.

Municipality of Daet )

AFFIDAVIT OF GUARDIANSHIP

That I, _______________________, of legal age, Filipino citizen,

married with residence and postal address at Purok 1, Barangay VII,
Mercedes, Camarines Norte, after having been sworn to in accordance
with law, hereby depose and say;

1) That I personally know the person of ____________________, who

was born on January 9, 2004 at Mercedes, Camarines Norte;

2) That _________________________________, is my daughter out of

my marriage to _______________________;

3) That ________________________ has been under my guardianship

and custody since her birth;

4) That I am executing this affidavit in order to confirm my

statements as above-mentioned and for the purpose claiming
death benefits under Fortune Life Insurance Co., Inc. in which
my daughter _______________________ is a beneficiary, and for
any purpose that this affidavit may serve.

IN WITNESS WHEREOF, I have hereunto set my hands this 9 th

day of August 2019 at Daet, Camarines Norte.

_______________________
Affiant
Voter’s ID: 1607-0042A-B0870LOB20000

SUBSCRIBED AND SWORN TO BEFORE ME THIS 9 th day of

August 2019 at Daet, Camarines Norte.