REPUBLIC OF THE PHILIPPINES)

City of Mabalacat )S.S.

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

AFFIDAVIT OF GUARDIANSHIP OF MINORS

I, _____________________________, Filipino, of legal age, and a resident of

_____________________________, after having been duly sworn in accordance with law,
hereby depose and state, that:

1. I am the parent of _____________________________, who was born on

_____________________________;

2. I am submitting a certified true copy of the Birth Certificate of my minor

son, _____________________________. A copy of the Birth Certificate is hereto
attached as Annex “A”;

3. _____________________________’s father, _____________________________

was insured under the Philippine American Life and General Insurance
Company (Philam Life) under policy #_______________________;

4. I, on behalf of my son, hereby lay claim insurance benefits on the policy;

5. 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 the Philam Life from any all
further obligations in connection with this claim;

6. I further undertake to refund Philam Life the amount paid to me including

interests thereon and indemnify Philam Life and/or third parties for any loss
or damages occasioned by such payment.

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

IN WITNESS WHEREOF, I have hereunto affixed my signature this 21 May 2020 at

Mabalacat City.

_________________________________

SUBSCRIBED AND SWORN TO BEFORE ME, a notary public in and for

Mabalacat City this _____________________________. Affiant personally came and
appeared with her
________________________________________________________________ ,
known to me as the same person who personally signed the foregoing instrument
before me and avowed under penalty of law to the whole truth of the contents of said
instrument.

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