AFFIDAVIT OF GUARDIANSHIP

I, ________________, of legal age, Filipino, married and with residence and

postal address at _________________, Kidapawan City, after being duly sworn to in
accordance with law, depose and state that:

1. I am the mother of the minor named below who is the beneficiary in the
Mortuary Claim/Death Benefit Claim of the late Inez T. Benemerito payable
by the Mediatrix Multi – Purpose Cooperative, Kidapawan City.

NAME OF MINOR DATE OF BIRTH AGE

________________________ _____________________

2. I am the guardian of the above-named minor;

3. The said minor is under my care and custody;

4. I am competent to receive on behalf of the said minor any

amount/benefit/proceeds due her;

5. I have not been diagnosed nor committed to a hospital or institution for

imbecile, insane, a vagrant or vicious person. I am not a habitual drunkard or
a habitual criminal, and have not abandoned, neglected, or refused to support
said minor or caused her to commit offenses against the law; and

6. I am executing this affidavit to confirm and affirm the foregoing facts and to
prove that I am the legal guardian of the above-named minor, and for
whatever legal purpose it may serve.

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

, 20 at .

___________________
Affiant

SUBSCRIBED AND SWORN to before me in the

this day of , by , who has
satisfactorily proven to me her identity through her
, valid until , that she is the
same person who personally signed before me the foregoing Affidavit of Guardianship
and acknowledged to me that she executed the same.

Doc. No. ;
Page No. ;
Book No. ;
Series of 2021.