Republic of the Philippines )

City of Zamboanga

) S.S.

x--------------------------x

AFFIDAVIT TO USE THE SURNAME OF THE FATHER/ACKNOWLEDGMENT

I, RAFFIE PAULINO DUJALI of legal age, Filipino citizen, and presently

residing at Tumaga Interior Masuhud Drive Zamboanga City, after having been
duly sworn to in accordance with law, do hereby depose and say:

1. That I am the biological father of DAREL IBAEZ DUJALI.

2. That the biological mother of the child is DIANE WAHIN IBAEZ.

3. That my child DAREL IBAEZ DUJALI was born on October 29, 2015 at
Zamboanga City.

4. That the facts of birth of my child were duly registered at the Office of
the Zamboanga City Civil Registrar.

5.That I, RAFFIE PAULINO DUJALI being the father of DAREL IBAEZ

DUJALI, hereby acknowledged and recognized him as my child
and legal heir.

6.

That I am allowing my child DAREL IBAEZ DUJALI to use my

surname DUJALI to be his surname in his Certificate of Live Birth.

7. That I execute this affidavit to attest to the truth of the above facts in
compliance with the provisions of Republic Act No. 9255.

IN WITNESS WHEREOF, I have hereunto set my hand this 6 th day of

December 2016 at Zamboanga City, Philippines.

RAFFIE PAULINO DUJALI

Affiant

SUBSCRIBED AND SWORN to before me this 6th day of December

2016, Zamboanga City Philippines, affiant exhibiting to me his competent
evidence of identity by way of Community tax Certificate issued at Zamboanga
City, Philippines on _______________.

Doc No. : _____

Page No.: ______
Book No.: ______
Series of 2016