REPUBLIC OF THE PHILIPPINES )

CITY OF BAGUIO ) ………………..)S.S.

AFFIDAVIT TO USE THE SURNAME OF FATHER

I, _______________ of legal age, single, Filipino, and with residence at

____________________________________________, after having been duly
sworn to in accordance with law, hereby depose and state:

1. That I am the mother of _______________ who was born on

_________________ at _______________________;

2. That I am willing to and have the capacity to consent that the surname
of my child will be that of her father, ________________;

3. That I am executing this affidavit to attest to the truth of the foregoing

facts and for all legal intents and purpose it may serve.

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

______________ at the Baguio City Philippines.

_______________________
Affiant

WITNESSED BY:

_______________ _______________

SUBSCRIBED AND SWORN to before me in Baguio City, Philippines this ___

day of __________ by the affiant being personally known to me.

Doc No.
Page No. Notary Public
Book
Series of 2017