REPUBLIC OF THE PHILIPPINES) Registry No.

__________
Province of Cam. Sur)
City of Naga )s.s.

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, Name of Affiant, of legal age, Civil Status, Filipino, and a resident

of Complete Address, 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_____________________ in my

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

2. I was born on Date of Birth at Place of Birth.

3. My birth was recorded under Registry No. ______ on Date of

Registration.

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

Instrument was recorded under Registry No. ____ on Date of Registration at
the LCRO/Philippine Foreign Service Post(PFSP) of ____________.

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.

_____________
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