Republic of the Philippines )

City of Tacloban ) S.S.

AFFIDAVIT OF THE MOTHER

I, ANNIE P. REPOLLO, of legal age, Filipino, single, and a resident of

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

1. That I am the mother of ADRIENNE WESLEY REPOLLO who was

born last Augus 11, 2000 in Tacloban City;

2. That I am very much willing to allow my Daughter to use the surname

of the father for whatever legal purposes it may serve;

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

in accordance with R.A 9255.

IN WITNESS WHEREOF, I have hereunto set my hand this

_____________ at _____________, Philippines.

ADRIENNE WESLEY REPOLLO

Affiant
ID No.

SUBSCRIBED and SWORN TO before me this ____________ at

Tacloban City, affiant exhibiting to me his competent evidence of identity by
way of ________________ issued at _____________ on ______________.

WITNESS MY HAND AND SEAL in the date and place mentioned

above.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2019.