REPUBLIC OF THE PHILIPPINES ) CITY OF MANDAUE ) S.S.

AFFIDAVIT OF GUARDIANSHIP
I, _________________________, of legal age, widow, Filipino and residing at
_____________________________ after being duly sworn to, in accordance with law, do
hereby depose and say: 1. That I am the mother of _______________________, a minor,
who has an interest in the proceeds of insurance on the life of the late
_______________________, my deceased husband, as well as the GSIS/SSS Fund and Pag-
Ibig Fund benefits of the said deceased; 2. That I am the guardian of the above-
named minor; 3. That the said minor is under my care and custody; 4. That I am
competent to receive on behalf of the said minor the proceeds of insurance of the
deceased, as well as the latter’s benefits under the GSIS/SSS Fund and Pag-Ibig
Fund and any amount due her; 5. That I am not an imbecile, insane, a vagrant or a
vicious person or 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. Done this _____ _______________________. day of
_______________________ at

Witness: _______________________

_______________________ Affiant

CORROBORATION We, _____________________________ and _____________________________,

both of legal age, Filipinos and residents of _______________________________ and
_________________________________, respectively, and _____________________
(relationship) and ____________________, respectively, hereby confirm the foregoing
statements of _______________________, to be true and correct.

_______________________ Affiant

_______________________ Affiant

SUBCRIBED AND SWORN to before me this _____day of _______________________ at

_______________________. Affiants exhibited to me their respective Identification
Cards/Residence Certificates as follows:
Name of Affiant CTC/ID No. Issued at Issued on / Expiry

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