I, _______________________________, Filipino, of legal age, single/married to
__________________________________ and resident of ______________________
_____________________________________, after having duly sworn to in accordance with
law, voluntarily depose and say:
1. That I am the father/mother of minor(s) _________________________________
_____________ who is/are ________________________ years old;
2. That said minor(s) is/are applying for a Philippine passport in connection with his/her
forthcoming trip to the ________________________________________;
3. That said minor(s) will be accompanied by his/her:
(relationship and name of person accompanying minor(s));
4. That though the minor’s father/mother is not here present, I am giving consent to said
minor’s travel in as much as:
______ said father/mother has earlier voluntarily and freely given his/her consent, with
no condition imposed whatsoever, and requested that said consent be relayed by
______ I have exclusive legal custody of minor (see attached divorce decree / death
certificate / etc.)
______ ___________________________________________________________
(state appropriate reason)
5. That I assume responsibility for the issuance of the passport and for allowing the trip of
said minor and further assume any and all obligations consequent thereto; and
6. That I am executing this Affidavit to attest to the truth of the above statement in
connection with said minor’s application for a Philippine passport.
IN WITNESS WHEREOF, I have hereunto set my hand this ___________ in the City of
New York
________________________________ ______________________________