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:
- I am the incumbent Punong Barangay of Barangay , _____ City;
- is one of the residents of our barangay;
- 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. ;
- 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;
- I hereby agree to be the said custodian of and undertakes to bring him to court whenever required;
- I am executing this affidavit to apprise all those concerned of foregoing facts and for whatever other legal purpose it may serve.
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_ .