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Republic of the Philippines)

Rodriguez, Rizal) S.S

I, AVELINA CONCHAS BERE, of legal age, Filipino citizen, and a
resident of Navarro Compound, Manggahan Rizal, hereby depose and state

1. That my minor child, JONATHAN BERE, was born out of wedlock on

November 7, 2016;

2. That on his baptismal day, his father Pedro Caingles caused the
child’s name to appear as “JONATHAN B. CAINGLES” even in the
absence of marriage between the latter’s parents;

3. That the child’s parents however never caused the child’s birth to be
registered at the Civil Registry of Rodriguez, Rizal where the child
was born;

4. That the mother of the child is now causing the late registration of
the child;

5. Considering the death of the child’s father on August 23, 2017, as

evidenced by the attached certificate of death, the father can no
longer consent to the use of his surname in favor of his son;

6. That premises considered, the mother is executing this affidavit to

attest to the truth so she may apply for the late registration of
Jonathan using the mother’s surname, “BERE”;

7. This affidavit has been executed as well in order to correct the name
of “Jonathan Caingles” to “Jonathan Bere”;

8. This Affidavit is not executed to evade obligations under the law but
to attest to the truth of the foregoing.

IN WITNESS WHEREOF, I have hereunto set my hand this

_____________ at Rodriguez, Rizal, Philippines.

SUBSCRIBED AND SWORN to before me this ________________

at Rodriguez, Rizal, Philippines, affiant exhibiting to me his competent
evidence of identity _____________________________.

Doc No. : ____

Page No.: ____
Book No.: ____
Series of 2018.