SWORN AFFIDAVIT

(Sinumpaang Salaysay)

I, MS. MARIA THERESA C. AQUINO single, 28 years of age, Filipino, and resident of
Barangay Malasin, Pozurrubio, Pangasinan, after having been duly sworn to in accordance with
law, hereby depose and state:
THAT

1. I am a single/unmarried and the Biological Mother of Kurt Michael Aquino;

2. My Son Kurt Michael Aquino was born on February 08, 2016 in Don Amadeo
J. Perez Sr. Memorial General Hospital

3. I am assigning my Mother MRS. MERCEDES C. AQUINO likewise of legal

age, married, Filipino, and resident of Barangay Malasin, Pozurrubio,
Pangasinan to be my Son’s temporary Guardian as I will be working as
Overseas Filipino Worker in Hongkong starting on December 09, 2019

4. Under the penalty of perjury, I declare that the above statement is true and
correct to the best of my knowledge and belief;

IN WITNESS WHEREOF, I have hereunto set my hand this 20th day of November
2019, at Dagupan City, Pangasinan

MS. MARIA THERESA C. AQUINO

P2696177B
Barangay Malasin, Pozurrubio, Pangasinan

SIGNED IN THE PRESENCE OF:

_____________________________ _____________________________

BEFORE ME, a Notary Public, personally appeared, who are known to me and known
to me to be the same person who executed the foregoing instrument and acknowledged under
oath that the same is executed as his free and voluntary act and deed.

WITNESS MY HAND AND SEAL, on the date and place first above written.

Doc. No.______; Notary Public

Page No. ______;
Book No.______;
Series of 2019

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