Republic of the Philippines )

xxxxxxxxxxxxxxxxxxxxxx ) 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 6 th 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.