Republic of the Philippines)

Province of Negros Oriental)S.S.

City of Dumaguete)
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JOINT AFFIDAVIT OF INTENT AND CONSENT

We, __________ and ______________, both Filipinos, of legal age, married and
presently residing at Jimalalud, Negros Oriental, Philippines, having been duly sworn in
accordance with law, hereby depose and state:

1. That we are the legitimate parents of _____________ who was born on ___________ in
_____________, Philippines.

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

3. That 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 daughter __________________ be adopted.

4. That we also signify our written consent, freely, willingly and voluntarily to have our
daughter ______________ be legally adopted by the spouses ________________ and
_________________ of Dumaguete City, Philippines in accordance with law.

5. That we are ready and willing, freely and voluntarily to abdicate our parental authority
over said child in favor of the spouses __________________ and ____________, who
are ____and _____years of age, respectively, and who are both 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. That we execute this affidavit to declare our intention and consent to the adoption of our
daughter __________________ as well as to the truth of the foregoing facts.

IN WITNESS WHEREOF, we have hereunto set our hands this____________at Dumaguete

CIty, Philippines.

__________________ ____________________
Affiant Affiant

JURAT