Republic of the Philippines )

City of Tacloban ) S.S.

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, MANELYN RAGAODAO GAVAN, of legal age, Filipino, single, and a

residents of Brgy. 37 Reclamation Area, Tacloban City, after having been duly
sworn to in accordance with law, hereby depose and state:

1. That I am seeking the use of surname “LAO” in the Certificate of Live Birth
of MERILYN GAVAN LAO who is my DAUGHTER, pursuant to R.A. No.
9255;

2. That she was born on July 17, 2017 at Tacloban City, Philippines;

3. That the birth was recorded under Registry No. ____________ on

_______________;

4. That the Public Documents executed by the father EFREN POSTRERO LAO
acknowledging MERILYN GAVAN LAO his biological daughter is hereto
attached as Annex-“A”;

5. That I am filing this affidavit at the Office of the Local Civil Registrar of
Tacloban City in accordance with R.A. 9255 and its implementing Rules and
Regulations;

6. That I hereby certify that the statements made therein are true and correct
to the best of my knowledge and belief;

IN WITNESS WHEREOF, I have hereunto set my hand this _____________

at Tacloban City, Philippines.

MANELYN RAGAODAO GAVAN

Affiant
SNHS ID No. 124287050132

SUBSCRIBED and SWORN TO before me this ____________ at Tacloban

City, affiant exhibiting to me her competent evidence of identity as stated above
bearing her name, signature, and picture.

Witness my hand and seal in the above date and place.

Doc. No. _____;

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