Republic of the Philippines )

xxxxxxxxxxxxxxxx, Laguna ) S.S.

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, xxxxxxxxxx, of legal age, single, Filipino and presently residing

at xxxxxxxxxxxxxxxxxxxxxxxx City, Laguna, Philippines, under
oath, depose and say:

1. That, I am the mother of xxxxxxxxxxxxxxxxxxxxx, who was

born on December xx, 2019 at
xxxxxxxxxxxxxxxxxxxxxxxxxxxxx City, Laguna;

2. That, at the time when my child was born, I and my child’s

father were not legally married hence my child was considered
an illegitimate child;

3. That, I am giving consent for the minor/child to use the

surname of xxxxxxxxxxxxxxxxxx the father of the child and
the same be reflected in his/her birth certificate:

4. That, I have executed this affidavit to affirm the veracity of the

foregoing statements and admit under oath of the foregoing
facts for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto signed my name on this 6th

day of January 2020 at Calamba City, Laguna.

xxxxxxxxxxxxxxxx
Affiant

SUBSCRIBED AND SWORN to before me this 6th day of January

2020 at Calamba City, Laguna, Philippines, affiant exhibiting to me her
competent evidence of her identity by way of Philhealth ID with no.
xxxxxxxxxxxxxxxxxxxx.

Doc. No. ______;

Page No.______; Notary Public
Book No.______;
Series of 2020.