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Republic of the Philippines}

Island Garden City of Samal}s.s.


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

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, MIGUELITO C. BACUS, of legal age, single, Filipino citizen and a resident of


Island Garden City of Samal, under oath, do hereby depose and say:

1. That I have been living with my Common Law Wife, DIZA LIMOSNERO
MODO since August 2009 at Purok 7, Moncado Village, Brgy. Peñaplata,
Island Garden City of Samal, Province of Davao del Norte;

2. During our conjugal union as Common Law Husband and Wife, she gave birth
to our child, KRIZ EURIKA LEMOSNIRO MODO as my biological daughter
who was born on July 30, 2009 at Well Care Midwife Clinic, Mc Arthur
Highway, Calinan, Davao City;

3. That in the birth certificate of our child, she was using the surname of her
mother as we were not yet married and I was not able to affix my signature
at the back of the Certificate of Live Birth of my daughter because I was not
present when her birth was recorded at the Local Civil Registrar of Davao
City;

4. That I am allowing my daughter, KRIZ EURIKA LEMOSNIRO MODO and


give my consent to use my surname in her Certificate of Live Birth and after
which she shall be now known as KRIZ EURIKA LEMOSNIRO MODO
BACUS;

5. That I am executing this affidavit to attest to the truth and veracity of the
foregoing facts and to apprise the concerned authorities therein and for
whatever legal purpose this affidavit may serve.
Affiant sayeth further none. This 30th day of July 2012, at Island Garden City of Samal,
Province of Davao del Norte.

MIGUELITO C. BACUS
Affiant
CTC No. 10445834
Issued on July 30, 2012
Issued at Island Garden City of Samal

SUBSCRIBED AND SWORN to before me this 30th day of July 2012, at Island Garden
City of Samal, Province of Davao del Norte.

Doc. No. __________; ATTY. ROSEMARIE BUENDIA-GARDE


Page No. __________; NOTARY - PUBLIC
Book No. __________; UNTIL DECEMBER 31, 2013
Series of 2012. ROLL NO. 47947
PTR NO. 4182046 11-17-11, IGACOS
IBP NO. 838545 11-15-11, Davao City
TIN NO. 101-172-720
MCLE III – 0007768, 02-01-2011

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