R.A. No.

9255
Republic of the Philippines) Registry No.: _______________
City of Meycuayan ) S.S.
Province of Bulacan

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, _______________________________________________, Filipino, Single, ___ years old , a

resident of _____________________________________________________________
after having been duly sworn to in accordance with law, do hereby declare by;

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

a.) _____ my Certificate of Live Birth / Report of Birth, pursuant to R.A. No. 9255
b.) _____the Certificate of Live Birth / Report Birth of ______________________________
who is my _______________ pursuant to R.A. No. 9255

2. I/He/She was born on ___________________________________ at Meycuayan, Bulacan

3. My/ The birth was recorded under Registry No.__________ on ___________________
4. The public document or the private handwritten instrument was recorded under Registry
No. ______________ on ________________at the Local Civil Registry Office (LCRO) of Caloocan
City
5. I am filing this AUSF at the LCRO of Meycuayan Bulacan 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 hereby affix my signature on this _____ day of
_________________,_________ at Meycuayan, Bulacan, Philippines.

______________________________
Signature over printed name

SUBSCRIBED AND SWORN to before me this ______ day of ______ 20____ in the City of
Meycuayan,Province of Bulacan, Philippines, affiant exhibiting his Community Tax Certificate
No. ________________ issued at __________________ on __________

Doc No. :_______

Page No. :_______
Book No. :_______
Series No.:_______