RA 9255 Form No.

1
(Revised May 2004)

Republic of the Philippines)

Province of Leyte ) S.S.
City of Tacloban )

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, ____________________________, of legal age, Filipino, and a resident of

_____________________________________________, after having been duly sworn to
in accordance with law, do hereby declare that:

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 on ______________ at ____________________________;
3. The birth was recorded under Registry No. ___________ on ______________;
4. The public document was recorded under Registry No. _________ on
_____________ at the LCRO of _________________________ (if applicable)
5. The surname to be changed is from ________________________ to
____________________________________, 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
a) __________________________________________
b) __________________________________________
c) __________________________________________
8. I am filing Affidavit at the LCRO of _________________________ in
accordance 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 signature this _____ day of
__________________, 20___.

_________________________________
Signature over printed name of Affiant

SUBSCRIBED AND SWORN to before me this ______________________ in the

City of Tacloban, affiant exhibiting his/her Community Tax Certificate No. ____________
issued on _______________ at ___________________, Philippines.

Doc. No. ___

Page No. ___
Book No. ___
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