RA 9255 Form No.

1 (Revised May 2004)

Republic of the Philippines City of Tacloban

) ) S.S.

Registry No.

AFFIDAVIT TO USE THE SURNAME OF THE FATHER I,

(Affiants Name)

of legal age,
(Citizenship)

, and resident of

Hereby declare that:

, after having been duly sworn to in accordance with law, do

1. I am seeking the change of surname in: a) my Certificate of Live Birth b) Certificate of Live Birth of who is my 2. I/He/She was born at on , 3. The birth was recorded under o Registry No. n 4. The public document was recorded under o Registry No. n at the (if LCRO of applicable). 5. The surname to be changed t is from o Pursuant to RA 9255. 6. I/The father have/has sought the consent of my child as shown by his/her attached document. (Applicable only if the child is 18 years old and above) 7. In support hereof, I submit the attached private handwritten instrument Supporting documents: (Use additional sheets, if necessary) a) b) c)

8. I am filling Affidavit at the in accordance LCRO of with RA 9255 and its implementing Rules and Regulations. 9. I hereby certify that the statements made herein are true and correct to the best of my knowledge and belief. 10.In truth whereof, I have hereunto affixed my day 2 signature this of 0

SUBSCRIBED AND SWORN to be before me day this of in the City of Tacloban, affiant exhibiting his Community Tax Certificate No. issued o . at n

Signature Over Printed Name of Affiant

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Administering Oath

Doc No. Page No. Book No. Series of 20

Republic of the Philippines City of Tacloban

) ) S.S.

AFFIDAVIT OF THE MOTHER

I, with law hereby depose and sayeth; THAT I am the LEGITIMATE mother of was born last , Tacloban City. , who , of legal age, Filipino and a resident of , after having been sworn to an oath in accordance

THAT I am very much willing to allow , my child to use the surname of the father for whatever legal purpose his birth be used; THAT I am executing this affidavit to attest to the truth of the following facts in accordance with RA 9255;

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IN WITNESS WHEREOF, I hereunto affix my signature this , .

day of

___________________ Affiant SUBSCRIBED AND SWORN to before me this , Tacloban City. day of

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