REPUBLIC OF THE PHILIPPINES) Registry No.

__________
CITY OF NAGA )S.S.

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, JANE DOE, 7-17 years of age, Filipino, and a resident of Wellville

Subdivision Bgy. San Felipe Naga City, after having been duly sworn to in
accordance with law, do hereby depose and state that:

1. I am seeking the use of the surname “SANTOS” in my Certificate of

Live Birth/Report of Birth, pursuant to R.A. No. 9255.

2. I was born on 30 March 2010 at Naga City, Camarines Sur.

3. My birth was recorded under Registry No. 069068 on 03 April 2010.

4. An Affidavit of Admission of Paternity or the Private Handwritten

Instrument was executed by my father GABY SANTOS expressly
recognizing filiation and acknowledging me as his child. The said
public document was duly recorded under Registry No. 097864 on 16
February 2019 at the LCRO/Philippine Foreign Service Post (PFSP) of
Naga City.

5. I am filing this Affidavit to Use the Surname of the Father at the

LCRO/PFSP of _____________ in accordance with RA 9255 and its
Revised Implementing Rules and Regulations.

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

IN WITNESS WHEREOF, I hereby affix my signature this ___ day of

______ 2020 at Naga City, Cam. Sur, Philippines.

JANE DOE
Affiant

SUBSCRIBED AND SWORN to before me this _____ day of January

2020 at Naga City, Cam.Sur, Philippines. Affiant exhibited to me his/her
______________, bearing his/her photograph and signature, to prove to me
that he/she is the same person who signed and executed the foregoing
Affidavit.

Doc No. ____

Page No. ____
Book No. ____
Series of 2020