Republic of the Philippines)

Province of ____________)S.S.
City/Municipality of ____________)
x-- - - - - - - - - - - - - - - - - - - x

A F F I D A V I T
(INTENT AND CONSENT TO ADOPTION OF CHILD)

I, ______________________, Filipino, of legal age, single and presently residing at

__________________, Philippines, hereby depose and state:

1. That I am the biological mother of the child who was born on ___________ in
__________________, Philippines.

2. That I have not, at any time abandoned the said minor child.

3. That I am unable to support the said child and that believing that it would be for his/her own
interest and benefit, I, hereby signify my written intent, freely and voluntarily to have my
son/daughter be adopted.

4. That I also signify my written consent, freely, willingly and voluntarily to have my son/daughter be
adopted by the spouses ______________________ and ______________________ of
__________________, Philippines.

5. That I am ready and willing, freely and voluntarily to abdicate my parental authority over the said
child in favor of the spouses ______________________ and ______________________, who are ___
and ___ years of age, respectively, and who both possessed of the necessary civil and legal rights as
well as the financial capacity to raise, rear and support the said child.

6. That I execute this affidavit to declare my intention and consent to the adoption of my
son/daughter as well as to the truth of the foregoing facts.

IN WITNESS WHEREOF, we have hereunto set our hands this __day of ______ at _______________,
Philippines.
____________________
Affiant

____________________
Witness

____________________
Witness
Republic of the Philippines)
Province of ____________)S.S.
City/Municipality of ____________)
x-- - - - - - - - - - - - - - - - - - - x

A F F I D A V I T
(INTENT AND CONSENT TO ADOPTION OF CHILD)

I, ______________________, Filipino, of legal age, single and presently residing at

__________________, Philippines, hereby depose and state:

1. That I am the bearer of the child who was not yet born.

2. That I have not, at any time aborted the said minor child.

3. That I am unable to support the said child and that believing that it would be for his/her own
interest and benefit, I, hereby signify my written intent, freely and voluntarily to have my
son/daughter be adopted.

4. That I also signify my written consent, freely, willingly and voluntarily to have my son/daughter be
adopted by the spouses ______________________ and ______________________ of
__________________, Philippines.

5. That I am ready and willing, freely and voluntarily to abdicate my parental authority over the said
child in favor of the spouses ______________________ and ______________________, who are ___
and ___ years of age, respectively, and who both possessed of the necessary civil and legal rights as
well as the financial capacity to raise, rear and support the said child.

6. That I execute this affidavit to declare my intention and consent to the adoption of my
son/daughter as well as to the truth of the foregoing facts.

IN WITNESS WHEREOF, we have hereunto set our hands this __day of ______ at _______________,
Philippines.

____________________
 Affiant

____________________
Witness

____________________
Witness