REPUBLIC OF THE PHILIPPINES

)
CITY/MUN. OF _____________________)

S.S.

AFFIDAVIT OF GUARDIANSHIP
I, _________________________________ of legal age, Filipino and residing at
_________________________________________________ after being duly sworn to,
in accordance with law, hereby depose and say:
That I am the ___________________ and guardian of the following minor/s who
(relationship)

has / have an interest in the proceeds of insurance on the life of the late
_________________________;

1.
2.
3.
4.

Full Name/s of minor/s

_______________________
_______________________
_______________________
_______________________

Date of Birth
_____________________
_____________________
_____________________
_____________________

Age
_______
_______
_______
_______

That the above mentioned minor/s is/are under my care and custody;
That I am competent to receive on behalf of the said minor/s the proceeds of
insurance of the deceased ________________________.
That I am not imbecile or an insane, vagrant or vicious person; and that I have
neither abandoned, neglected or refused support for said minor/s or cause him / her / them
to commit offenses against the law.
________________________
Witness

__________________________
Affiants Signature

CORROBORATION
We, _____________________________ and _____________________________
both of legal age, Filipinos and residents of _______________________________ and
_________________________________, respectively, and _____________________
(relationship)

and ____________________, respectively, hereby confirm the foregoing statements of

(relationship)

Mr./Mrs. ____________________________, to be true and correct.

Name of Affiant

Signature

CTC No.

Issued at

Issued on

_____________________ ________________ ___________ _________ _________

_____________________ ________________ ___________ _________ _________
SUBCRIBED AND SWORN to before me this_________day of
_______________ 20_____, at _____________________. Affiants exhibited to me their
respective residence certificates as follows:

_____________________________
Notary Public
Doc. No.
Page No.
Book No.
Series of

__________________
__________________
__________________
__________________

CLAIMS-038-0802-1