Registry Number:____________

Republic of the Philippines_____)

Province of Agusan del Norte___) S.S
Municipality of Santiago_______)

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, NANCY GOMEZ BARTOLINE__, __Filipino_, __Single_ , _27__, years old, a

(Affiant’s Name) (Citizenship) (Civil Status) (Age)
Resident of ___P-4, La Paz, Santiago, Agusan del Norte______ after having been duly sworn
(Complete Address)
To in accordance with law, do hereby declare that:

1. I am seeking to use the surname _____ABATAYO______ in:

a. / /my Certificate of Live Birth/Report of Birth, pursuant to R.A No. 9255.
b. /X/ the Certificate of Live Birth/Report of Birth of PRINCESS FIONNAH B.
ABATAYO
(Complete Name of Child)
who is my ________________daughter______________, pursuant to R.A No. 9255.
(Relationship of the Affiant to the Child)
2. I/He/She was born ___9 September 2020__ at Santiago, Agusan del Norte, Philippines.
(Date of Birth) (Municipality) (Province) (Country)
3. My/The birth was recorded under Registry No. __________on__________( If Applicable).
4. The Public Document or the Private Handwritten instrument was recorded under
Registry No. __________N/A_______ on ________N/A___________ at the Local Civil
(Registry Number) (Date of Registration)
Registry Office (LCRO) Philippine Foreign Service Post (PFSP) of
_____________________N/A______________________________(If applicable).
(Municipality) (Province) (Country)
5. I am filing this AUSF at the LCRO/PFSP of Santiago, Agusan del Norte, Philippines
(Municipality) (Province) (Country)
in accordance with R.A No. 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.
7. In witness whereof, I affix my signature on ______ day of _______________, 2020 at
Santiago, Agusan del Norte.

NANCY GOMEZ BARTOLINE

Signature over printed name of affiant
CEI:___________________________
Date issued ____________________

SUBSCRIBED AND SWORN to before me this _______ day of ___________________

2020, at _________________________, Philippines, affiant exhibiting her above described ID
shown above as competent evidence of her identity.

Doc. No. ______________;

Page No. _____________;
Book No. _____________;
Series of 2020