Scribd
Upload
132 views1 page

RA 9255 Affidavit for Surname Change

This document is an affidavit form used to change a surname to that of the father in accordance with RA 9255. It contains information such as the applicant's name and address, birth details of the applicant or child whose name is being changed, the current and requested surnames, a statement that consent was obtained if the child is over 18, and a certification that the statements are true. The applicant must sign the affidavit before a notary.

Uploaded by

Mark Lojero
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
132 views1 page

RA 9255 Affidavit for Surname Change

This document is an affidavit form used to change a surname to that of the father in accordance with RA 9255. It contains information such as the applicant's name and address, birth details of the applicant or child whose name is being changed, the current and requested surnames, a statement that consent was obtained if the child is over 18, and a certification that the statements are true. The applicant must sign the affidavit before a notary.

Uploaded by

Mark Lojero
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

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. ___
SERIES OF 20__

You might also like