REPUBLIC OF THE PHILIPPINES

FOURTH JUDICIAL REGION

REGIONAL TRIAL COURT
Branch ____,
Batangas City, Batangas

IN RE: PETITION FOR ADOPTION SP PROC No. __________

OF MINOR CHILD _______________

____________________,
Petitioner
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JUDICIAL AFFIDAVIT of ___________________________S

___________________________

I, ___________________, of legal age, single, natural born Filipino, and a

resident of __________________________________, state under oath, as follows:

PRELIMINARY STATEMENT

The person examining me is Atty. _________________ with office address at

_______________________. The examination is being held at the same address. I
am answering his questions fully conscious that I do so under oath and may
face criminal liability for false testimony and/or perjury.

FORMAL OFFER: The testimony of the petitioner, ____________________ is being

offered to prove:

1. The factual basis of the Petition;

2. That the petitioner is of legal age;
3. That she is in possession of full civil capacity and legal rights;
4. That she has not been convicted of any crime involving moral
turpitude;
5. That she is emotionally and psychologically capable of caring for her
child;
6. That she is the sister of the biological father of the adoptee;
7. That she is in position to support and care for her child in keeping
with the means of the family;
8. That she has undergone pre-adoption services as required by Section
4 of R.A. No. 8552; and
9. That she possess all the qualifications and none of the
disqualifications to adopt _________________, and for such other
purposes relevant to this case.

Q: Ms. Witness, kindly state your name, age, civil status, citizenship,
 and residence.
A: ___________________, ______ years old, single, natural born Filipino,
and a resident of __________________________________,

Q: How are you related to the petitioner in this case?

A: I am the Petitioner sir.

Q: Do you know why you are giving this judicial affidavit?

A: Yes sir, to serve as my testimony as the petitioner in this case.

Q: Are you referring to the cae of In Re: Petition for Adoption of Minor
Child _______________ pending before RTC Branch 1, Family Court,
Batangas City?
A: Yes sir.

Q: Ms. Witness, I am showing to you a Petition consisting of ________

pages and a signature in the Verification and Certification of Non-
Forum Shopping. Kindly go over it and tell us its relation, if any,
with the instant case?
A: This is the same petition that I filed before the Family Court and
that is my signature in the Verification and Certification of Non-
Forum Shopping.

Manifestation:
May we request, Your Honor, that the following documents be
marked as Exhibits for the Petitioner, as follows:

Exhibit ____ : Petition consisting of ______ pages.

Exhibit ____ : Verification and Certification of Non-Forum
Shopping.
Exhibit ____ : Signature on top of the name
___________________________s ___________________________.

Q: Ms. Witness, you mentioned that you are presently residing at

________________________, what is your proof, if any, with regard to
the said fact?
A: A Barangay clearance was issued to me by Barangay Captian of
___________________________ sir.of a Barangay Clearance issued

Q: I am showing to you a copy of a Barangay Clearance issued by

Barangay Captain, __________________ of Brgy.
_____________________, Batangas City, attached to the records of
this case and marked as Annex “____”. Can you go over it and tell
us its relation, if any, with the Barangay Clearance you
mentioned?
A: It is the same sir.

Manifestation:
May we request, Your Honor, that the following documents be
marked as Exhibits for the Petitioner, as follows:

Exhibit ____ : Barangay Clearance issued by Barangay Captain

_____________ of Brgy. ______________, Batangas City.
Q: Ms. Witness, what is your main reason, if any, for filing this
Petition?
A: I filed this petition in order to adopt the minor child
___________________________ ___________________________.

Q: Ms. Witness, what is your relationship, if any, with

___________________________?
A: Actually sir, I am her aunt, ___________________________ was born
on ___________ at _________________. Her biological parents are
________________ and ________________. _________________ is my
brother sir.

Q: What is/are your proof, if any, with regard to said birth of

___________________________?
A: A copy of the Certificate of Live Birth of ___________________________
was issued by the PSA to me and ______________.

Q: Ms. Witness, I am showing to you a copy of a Certificate of Live

Birth issued by the PSA pertaining to a person named
___________________________ ___________________________, attached
to the records of this case and marked as Annex “___”. Kindly go
over it and tell us its relation, if any, with the Certificate of Live
Birth you mentioned.
A: It is the same document that I mentioned sir.

Manifestation:
May we request, Your Honor, that the following documents be
marked as Exhibits for the Petitioner, as follows:

Exhibit ____ : Certificate of Live birth of

___________________________s
___________________________ issued by PSA.

Q: What happened, if any, after the birth of

___________________________?
A: The biological parents of ___________________________ were and are
continuously unable to support the minor child and believe that it
is for the best interest and benefit of the minor child that she be
adopted by me. After her birth, it was me who was supporting her
with all her needs, from her milk formula, vaccinations, clothes,
toys and other needs. She and her parents were also living with
me. Also, ___________________________ is closely related to me.

Q: And then what happened, if any?

A: The biological parents of ___________________________, my brother
and sister-in-law, voluntarily and freely signified their intent and
consent to have me adopt ___________________________.

Q: What is your proof, if any, with regard to the said fact of intent and
consent by the biological parents as regards the adoption of
___________________________?
A: There is a public instrument executed by the biological parents of
___________________________ attesting that they freely and
voluntarily express their consent and intent for said adoption.
Q: Ms. Witness, I am showing to you a copy of Affidavit of Intent and
Consent to Adoption of a Minor Child, attached to the records of
this case and marked as Annex “___”. Kindly go over it and tell us
its relation, if any, with the Certificate of Live Birth you mentioned.
A: It is the same document that I mentioned sir.

Manifestation:
May we request, Your Honor, that the following documents be
marked as Exhibits for the Petitioner, as follows:

Exhibit ____ : Affidavit of Intent and Consent to Adoption of a Minor

Child.

Q: Ms. Witness, what happened next, if any?

A: In fact sir, ever since, I have loved, cared, and treated
___________________________ as that of my own child. Because of
the same, ___________________________, since then up to present,
has considered me as her own mother.

Q: Ms. Witness, you earlier mentioned that you desire to adopt

___________________________, what is your reason, if any?
A: Sir, I am in the honest belief that adopting
___________________________ will serve her best interest and well-
being because I am not only more than suitable and qualified as
legitimate mother but also can help her grow into a responsible,
well-adjusted, and happy child. Her best interest will be better
served in an environment characterized by emotional stability and
material sufficiency. An environment that has been provided, being
provided and will be provided by me, then up to present.

Q: What is your basis, Ms. Witness, if any, for saying that the best
interest of ___________________________ will be better served by
allowing you to adopt her?
A: Because sir, I possess all the qualifications and none of the
disqualifications to adopt ___________________________.

Q: What is/are the factual circumstance/s, if any, that support/s the

assertion that you are qualified to adopt
___________________________?
A: I am gainfully self-employed as a sole proprietor/owner of
___________________, situated at _____________________. My
salary/income can provide material sufficiency for the adequate
upbringing of ___________________________, thus, I am in the
position to support and care for said child in keeping with the
means of the family.

Q: What is your proof, if any, with regard to your self-employment?

A: A business permit was issued by the Office of the Batangas City
Mayor in my favor sir.

Q: Ms. Witness, I am showing to you a copy of Business permit issued

by the Office of the Batangas City Mayor, attached to the records of
this case and marked as Annex “___”. Kindly go over it and tell us
its relation, if any, with the Business permit that you mentioned.
A: It is the same document that I mentioned sir.
 Manifestation:
May we request, Your Honor, that the following documents be
marked as Exhibits for the Petitioner, as follows:

Exhibit ____ : Business permit issued by the Office of the Batangas

City Mayor

Q: What other fact/s, if any, support/s your qualification to adopt

___________________________?
A: I am ______________ years older that ___________________________ for
I was born on _____________.

Q: What is your proof, if any, to support your claim that you are
__________ years older than ___________________________?
A: My Certificate of Live Birth sir.

Q: Ms. Witness, I am showing to you a copy of Certificate of Live Birth

of one ___________________________s ___________________________
issued by PSA, attached to the records of this case and marked as
Annex “___”. Kindly go over it and tell us its relation, if any, with
the Certificate of Live Birth that you mentioned.
A: It is the same document sir.

Manifestation:
May we request, Your Honor, that the following documents be
marked as Exhibits for the Petitioner, as follows:

Exhibit ____ : Certificate of Live Birth of one

___________________________s
___________________________ issued by PSA.

Q: What other fact/s, if any, support/s your qualification to adopt

___________________________?
A: Sir, I am in possession of full civil capacity and legal rights, a
person of good moral character, and a person who is emotionally
and psychologically capable of caring for
___________________________.

Q: What is your proof, if any, to support your claim that you possess
good moral character and you are indeed emotionally and
psychologically capable of caring for ___________________________?
A: There is a certification issued to me by the Barangay Captain of
___________________. Said person has vouched that I am a well-
respected resident of our Barangay, peace-loving, God fearing, and
dedicated individuals to our family, parish, and work.

Q: Ms. Witness, I am showing to you a copy of the Certification issued

by the Barangay Captain of _______________________, attached to
the records of this case and marked as Annex “___”. Kindly go over
it and tell us its relation, if any, with the Certification that you
mentioned.
A: It is the same document that I mentioned sir.

Manifestation:
 May we request, Your Honor, that the following documents be
marked as Exhibits for the Petitioner, as follows:

Exhibit ____ : Certification issued by the Barangay Captain of

_______________________.

Q: What other fact/s, if any, support/s your qualification to adopt

___________________________?
A: I am also physically healthy to become a parent of
___________________________.

Q: What is your proof, if any, to support your claim that you are
physically healthy to become a parent of the minor child?
A: I have undergone medical check-up before and was cleared of any
significant findings by ____________________ which issued to me a
medical certificate.

Q: Ms. Witness, I am showing to you a copy of the Medical Certificate

issued by ____________________, attached to the records of this case
and marked as Annex “___”. Kindly go over it and tell us its
relation, if any, with the Medical Certificate that you mentioned.
A: It is the same document that I mentioned sir.

Manifestation:
May we request, Your Honor, that the following documents be
marked as Exhibits for the Petitioner, as follows:

Exhibit ____ : Medical Certificate issued by ____________________.

Q: What other fact/s, if any, to support your petition?

A: I obtained a clearance bearing “no record on file” from the National
Bureau of Investigation (NBI), a Police Clearance from the
Batangas City Police Station and Court clearances from MTC and
RTC of Batangas City. In connection with this, I have never been
charged nor convicted for any violation of law/ordinance in the
said city and have not been charged with any felony nor
misdemeanor before the Municipal Trial Court in Cities and
Regional Trial Court both in Batangas City.

Q: Ms. Witness, I am showing to you a copy of the NBI Clearance,

Police Clearance, MTC Clearance and RTC Clearance, attached to
the records of this case and marked as Annexes “___”, “____”,
“____”, and “____”. Kindly go over these documents and tell us its
relation, if any, with the different clearances that you mentioned.
A: Those are the same documents that I mentioned sir.

Manifestation:
May we request, Your Honor, that the following documents be
marked as Exhibits for the Petitioner, as follows:

Exhibit ____ : NBI Clearance;

Exhibit ____ : Police Clearance;
Exhibit ____ : MTCC Clearance;
Exhibit ____ : RTC Clearance;

Q: What other fact/s, if any, to support your petition?

A: I have already attended and completed the Forum/Seminar on
Adoption and Foster Care conducted by the DSWD field offce IV-A
on _____________ at Alabang Zapote Road, Muntinlupa City in
compliance with Article III, Sec. 4 of Implementing Rules and
Regulations of Republic Act No. 8552 or the Domestic Adoption Act
of 1998.

Q: Ms. Witness, I am showing to you a copy of the Certificate of

Attendance issued by DSWD Field office IV-A, attached to the
records of this case and marked as Annex. Kindly go over it and
tell us its relation, if any, with the Certificate of Attendance that
you mentioned.
A: It is the same document that I mentioned sir.

Manifestation:
May we request, Your Honor, that the following documents be
marked as Exhibits for the Petitioner, as follows:

Exhibit ____ : Certificate of Attendance issued by DSWD Field office

IV-A.

Q: What other fact/s, if any, that you wish to add Ms. Witness?
A: None sir.

Q: What is your prayer in your petition Ms. Witness?

A: That, first, judgment be rendered granting the adoption of
___________________________ ___________________________. Second,
declaring ___________________________ ___________________________
for all intents and purposes to be my legitimate daughter by
adoption and for her to enjoy all the rights pertaining thereto.

Q: Do you have anything more to say?

A: Nothing more for now sir. I will tell the court other matters if
needed.

Q: Ms. Witness, with regards to the petition that you filed before the
Honorable Court, do you confirm and affirm the contents of the
same?
A: Yes sir.

Q: Having confirmed the contents of your petition, do you swear

under your present oath, the veracity and truthfulness of
itscontents?
A: Yes sir.

Q: Do you confirm and affirm the contents of this Judicial Affidavit?

A: Yes sir.

Q: If it is so, would you affix your signature herein?

A: Yes sir. (witness affixed her signature)

Manifestation:
May we request, Your Honor, that the following documents be
marked as Exhibits for the Petitioner, as follows:
 Exhibit ____ : Judicial Affidavit of ___________________________s
___________________________.

IN WITNESS WHEREOF, I have hereunto set my hand this

___________________ at _________________, Philippines.

___________________________S ___________________________
Affiant

SUBCRIBED AND SWORN TO before me this _______________________,

affiant exhibiting to me her passport with number KJ0690046 valid until April
20, 2028 to prove her identity.