Anda di halaman 1dari 2

Republic of the Philippines )

x-- - - - - - - - - - - - - - - - - - - - - - - - - x


I, ______________________ of legal age, single, Filipino citizen and a resident
of __________________________ Philippines, having been duly sworn in accordance
with law, hereby depose and state:
1. That I am the biological mother of ____________________________
who was born on __________________ at _____________________.
2. That I have not, at any time abandoned said minor child.
3. That I was unable to support said child and that believing that it
would be for (his/her)own interest and benefit, we, hereby signify our written
intent, freely and voluntarily to have our(son/daughter) ____________be
4. That I also signify my written consent, freely, willingly and
voluntarily to have my (son/daughter) ____________ be legally adopted by
SPS. Adap Tor and Adap Ter of House Number, Philippines in accordance with
5. That I am ready and willing, freely and voluntarily to abdicate my
parental authority over said child in favor of the SPS. Adap Tor and Adap Ter,
who are ____and _____years of age, respectively, and who are both
possessed of the necessary civil and legal rights as well as the financial
capacity to raise, rear and support said child, after the adoption proceeding
had been instituted and an order of adoption be issued.
6. I voluntarily and freely give the custody and care of my child SPS.
Adap Tor and Adap Ter who are the prospective adopting parents while the
adoption process is being worked out in accordance with laws of the Republic
of the Philippines.
7. That I execute this affidavit to declare my intention and consent to
adopt my (son/daughter) _______________ as well as to the truth of the
foregoing facts.
IN WITNESS WHEREOF, we have hereunto set our hands this __________ at
____________, Philippines.

SUBSCRIBED AND SWORN to before me this ________________ at
_______________, Philippines. Affiant exhibited to me her _______________ with ID No.
_________________ bearing her photograph and genuine signature as competent proof of
her identity.
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 2017.