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.