Republic of the Philippines)

City of Angeles ) S.S.

AFFIDAVIT OF INTENT AND

CONSENT TO ADOPTION OF CHILD

We, ______________and ______________, both Filipinos, of legal age,

married and presently residing at ______________, having been duly sworn in
accordance with law, hereby depose and state that:

1. We are the legitimate parents of ______________who was born on

______________ in ______________;
2. We have not, at any time abandoned said minor child.

3. We are unable to support said child and that believing that it would be for
her own interest and benefit, we, hereby signify our written intent, freely and
voluntarily to have our child ______________ be adopted;

4. We also signify our written consent, freely, willingly and voluntarily to have
our child ______________be legally adopted by ______________ in
accordance with law;

5. We are ready and willing, freely and voluntarily, to abdicate our parental
authority over said child in favor of ______________, who is ___ years of
age and who is 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. We execute this affidavit to declare our intention and consent to the adoption
of our child ______________ as well as to the truth of the foregoing facts.

IN WITNESS WHEREOF, I have hereunto set my hand this ___th day of

______________ 2019 in Angeles City, Philippines.

______________
Affiant Affiant
VIN ______________ Driver’s License No. ______________
Valid until ______________

SUBSCRIBED AND SWORN to before me this ____th day of __________ 2019 in

Angeles City, Philippines, by ______________ and ______________, who have
satisfactorily proven to me their identities through their proof of identity as
indicated below their respective names and who are the same persons who
personally signed before me the foregoing Joint Affidavit and acknowledged that
they executed the same.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2019.