REPUBLIC OF THE PHILIPPINES )

Province of
)
Municipality of
)

AFFIDAVIT OF GUARDIANSHIP
I , __________________________ of legal age , ________ and residing at
__________________________ after being duly sworn to in accordance with law and says :
That I am the ______________ of the minors mentioned below who have an interest in
the proceeds of the death aid benefit of the late _________________________
Payable to the PHILIPPINE PUBLIC SCHOOL TEACHERS ASSOCIATION.
NAME OF MINORS

Date of Birth

Age

1.
2.
3.
4.
5.
That the above mentioned minors are under my care and custody :
That I am competent to receive on behalf of the said minors the amount due them in the
proceeds of the death aid benefit of the deceased :
That I am not embecile, vagrant or vicious person or a habitual drunkard or a criminal
and has not abandoned, neglected, or refused to support said minors or cause them to commit
offenses against the law :
That the minors named above do not each own any property, the aggregate amount of
which exceeds TWO THOUSAND PESOS ( P 2,000 )
______________________
Affiant
CORROBORATION
We, ____________________________ AND ___________________________
______________________________________ and ____________________________
respectively, both of legal age, hereby confirm the foregoing statement of ___________
____________________ to be true and correct.
______________________
Witness
______________________
Official Title

______________________
Witness
______________________
Official Title

SUBSCRIBED AND SWORN to before me this ____ of ___________________

200 __ at _____________. Affiant exhibited to me their residence Certificate No. respectively :
A. _________________ issued at ___________________ on __________________
B. _________________ issued at ___________________ on __________________
C. _________________ issued at ___________________ on __________________
Doc No. _________
Page No. _________
Book No. ________
Series No. ________

NOTARY PUBLIC