CITY OF (PLACE) ) S.S.
AFFIDAVIT
OF GUARDIANSHIP
I, (NAME OF
AFFIANT), of legal age, widow/widower, Filipino and a resident of (Place of Residence), after being duly
sworn to, in accordance with law, do hereby depose and say:
1.
That I am the mother/father of (NAME OF DAUGHTER/SON), a minor, who has an interest in the
proceeds of insurance on the life of the late (Name of Deceased Husband/Wife), my deceased husband/wife, as well
as the (Name of Insurance
Company/Fund-1), (Name of Insurance
Company/Fund-2) and (Name of
Insurance Company/Fund-3) 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 (Name of Insurance
Company/Fund-1), (Name of Insurance
Company/Fund-2) and (Name of
Insurance Company/Fund-3), and any amount due him/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 him/her to
commit offenses against the law.
Done this
(Date) at (Place).
(NAME OF
AFFIANT)
Affiant
Witness: _______________________
CORROBORATION
We, (Name of
Corroborator-1) and (Name of
Corroborator-2), both of legal age, Filipino and residents of (Place of Residence of C-1) and (Place of Residence of C-2),
respectively, and (Relationship to the
Affiant), hereby confirm the foregoing statements of (Name of Affiant), to be true and correct.
(Name of
Corroborator-1) (Name
of Corroborator-2)
SUBCRIBED AND SWORN to before me this (Date) at (Place). Affiants exhibited to me their respective Identification
Cards/Residence Certificates as follows:
Name of Affiant
|
CTC/ID No.
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Issued at
|
Issued on / Expiry
|
(Affiant)
|
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(Corroborator-1)
|
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(Corroborator-2)
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Doc. No. _____;
Page No. _____;
Book No. _____;
Series of _____.