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REPUBLIC OF THE PHILIPPINES)

) Ss.

AFFIDAVIT OF UNDERTAKING AS CUSTODIAN

I, , Filipino, of legal age, single/married/widow/widower, and


a resident of , after having been duly sworn to in
accordance with law, depose and state, that:

1. I am the incumbent Punong Barangay of Barangay ,


City;

2. is one of the residents of our barangay;

3. I was informed that has applied for probation having been


convicted for the crime of by the Trial Court of
, Branch _, and docketed as Criminal Case No. ;

4. I was further made to understand that desires to be released on


recognizance pending the resolution of her application for probation, and needs a
custodian for this purpose;

5. I hereby agree to be the said custodian of and undertakes to


bring him to court whenever required;

6. I am executing this affidavit to apprise all those concerned of foregoing facts and
for whatever other legal purpose it may serve.

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


, at , Philippines.

Affiant

SUBSCRIBED AND SWORN to before me this day of , at


, Philippines. The identity of the affiant is established by his Philippine Passport
No. _, issued on_ .

NAME OF PUBLIC ATTORNEY


Public Attorney
(Pursuant to R.A. 9406)

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