REPUBLIC OF THE PHILIPPINES }

CITY OF ___________ } S.S.

AFFIDAVIT STATING CIRCUMSTANCES OF BEING A SOLO PARENT

I, ______________, a Filipino Citizen of legal age, single, residing at

______________________ City, after being sworn to in accordance with law, do hereby depose
and state that:
1. I am the mother/father of ____________, female/male, 16 years of age, and born on 15
JANUARY 2004;

2. I and the biological father/mother of my daughter/son never got married and we have
never communicated ever since our separation after my daughter’s/son’s birth;

3. I was left alone and with the sole responsibility of parenthood and I am the one fully
supporting my daughter/son and her needs such as schooling, housing, medicine, etc.;

4. I am executing this Affidavit to attest to the truth of the foregoing and to secure a Solo
Parent ID and to receive the benefits under the Solo Parents’ Welfare Act.

FURTHER AFFIANT SAYETH NAUGHT

_______________________
Affiant

SUBSCRIBED AND SWORN TO before me this __ day of _______ 2020, affiant exhibiting
to me her _______________ ID issued by the ___________________ on ___________________.

Notary Public

Doc No.____
Page No.____
Book No.___
Series of 2020