REPUBLIC OF THE PHILIPPINES )

CITY OF __)

AFFIDAVIT OF GUARDIANSHIP
I, _________________________________ of legal age, Filipino and
residing at ___, after being duly sworn to, in accordance with law,
hereby depose and say:
a. That I am the ____ and legal guardian of the following
children of the late ___ who have interest in the insurance
proceeds of _____;
Full Name/s of minor/s
1. _____________________
2. _____________________

Date of Birth
_____________________
_____________________

Age
_____
_____

b. That the above mentioned minors are under my care and

custody;
c. That I am competent to receive on behalf of the said minors
the proceeds of insurance of the deceased ___.
d. That I am not imbecile or an insane, vagrant or vicious
person; and that I have neither abandoned, neglected or
refused support for said minors or cause them to commit
offenses against the law.
Affiant Further sayeth naught.
IN WITNESS WHEREOF, I have hereunto set my hand and affixed
my signature this __of November, 2014 City of ___, Philippines.

______________________________
Affiant

SUBSCRIBED AND SWORN to before me in the City of ____this __

of November, 2014. I have identified affiant through her
Identification Card with No. ___ issued on____ at____.

________________________
Notary Public
Doc. No. ______
Page No. ______
Book No. _____
Series of _____