Republic of the Philippines )

Province of Laguna )
Municipality of Kalayaan ) S.S.

AFFIDAVIT OF GUARDIANSHIP

I, LEONORA GAGARIN PADALLAN, of legal age, Filipino, widowed and with address at
Purok no.1, Barangay San Antonio, Kalayaan, Laguna after having been duly sworn to in
accordance with law, depose and state:

1. That I am the grandmother and guardian of the student, CLARK JENDRIX PADALLAN
CABILLON born on October 12, 2005, who have an interest in applying for the Department of
Science and Technology (DOST) scholarship;

2. That the above-mentioned student is under my care and custody;

3. That I am competent to certify for the DOST scholarship of the said student;

4. That I am not an imbecile, insane, vagrant, or vicious person or a habitual drunkard or a

habitual criminal, and have not abandoned, neglected or refused to support the said minor or
cause him to commit offenses against the law;

5. As such, I am executing this Affidavit to attest to the truth of the foregoing and for whatever
legal intents and purposes it may duly serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 20th day of November 2023 at
Kalayaan, Laguna, Philippines.

LEONORA GAGARIN PADALLAN

Affiant

SUBSCRIBED and SWORN to before me this 20th day of November 2023 at

Kalayaan, Laguna, Philippines, affiant exhibited to me her Senior Citizen ID Card with no. SA-
451, as competent proof of her identity.

Notary Public

Doc. No.

Page No.

Book No.

Series of 2023