R.A. No. 9255 Form No.

1
(Revised March 2016)

Registry Number: _____________

REPUBLIC OF THE PHILIPPINES )

MUNICIPALITY OF LA TRINIDAD) s.s.

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, JO-ANN JULIAN PANNGAYAN, Filipino, single, 20 years old and a resident of

PA-101 Upper Wangal, La Trinidad, Benguet, Philippines, after having been duly
sworn to in accordance with law, do hereby declare that:

1. That I am seeking to use the surname BALANCIA in:

a. my Certificate of Live Birth, pursuant to R.A. No. 9255.

b. The Certificate of Live Birth/Report of Birth of HEATHER ROSE who

is my DAUGHTER pursuant to R.A. No. 9255.

2. He was born on MARCH 13, 2020 at La Trinidad, Benguet;

3. The birth was recorded under Registry No. __N/A__ on __N/A__ (If applicable);

4. The Public Document of the Private handwritten Instrument was recorded

under Registry No. __N/A__ on __N/A__ at the Local Civil Registry Office
(LCRO)/Foreign Service Post (PFSP) of __N/A__;

5. I am filing this AUSF at the LCRO of LA TRINIDAD, BENGUET, PHILIPPINES 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 this 6TH day of November 2020
at La Trinidad, Benguet.

JO-ANN JULIAN PANNGAYAN

Affiant
CTC 22122104

SUBSCRIBED AND SWORN to before me this 6TH day of November 2020 at La

Trinidad, Benguet, Philippines. Affiant personally appears before me and presented to
me a competent evidence of their identity appearing below her name.

VICTOR B. SINGA JR.

Doc. No. ; Notary Public - Province of Benguet
Page No. ; NPPC No. 18-NC-0444 – Until December 31, 2020
2/F Lumiqued Bldg., JC 179 Km. 5 Pico, La Trin., Beng.
Book No. XVI;
PTR NO. 6316871, January 3, 2020
Series of 2020.
IBP LIFETIME MEMBER NO. 017081, Baguio-Benguet
ROLL NO. 68089; Page No. 132; Book No. XXIX, May 26, 2017
R.A. No. 9255 Form No. 1
(Revised March 2016)

Registry Number: _____________

REPUBLIC OF THE PHILIPPINES )

MUNICIPALITY OF LA TRINIDAD) s.s.

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, DAMARIS PAYANGDO GIRON, Filipino, single, 23 years old and a resident of

Natubleng, Buguias, Benguet, Philippines, after having been duly sworn to in
accordance with law, do hereby declare that:

8. That I am seeking to use the surname BALINGIT in:

a. my Certificate of Live Birth, pursuant to R.A. No. 9255.

b. The Certificate of Live Birth/Report of Birth of AZIEL SHAWN who is

my SON pursuant to R.A. No. 9255.

9. He was born on OCTOBER 10, 2020 at La Trinidad, Benguet;

10.The birth was recorded under Registry No. __N/A__ on __N/A__ (If applicable);

11.The Public Document of the Private handwritten Instrument was recorded

under Registry No. __N/A__ on __N/A__ at the Local Civil Registry Office
(LCRO)/Foreign Service Post (PFSP) of __N/A__;

12.I am filing this AUSF at the LCRO of LA TRINIDAD, BENGUET, PHILIPPINES in

accordance with R.A. No. 9255 and its Revised Implementing Rules and
Regulations.

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

14.In witness whereof, I hereby affix my signature this 19 TH day of October 2020 at
La Trinidad, Benguet.

DAMARIS PAYANGDO GIRON

Affiant
PHIC 04-250832093-5

SUBSCRIBED AND SWORN to before me this 19TH day of October 2020 at La

Trinidad, Benguet, Philippines. Affiant personally appears before me and presented to
me a competent evidence of their identity appearing below her name.

VICTOR B. SINGA JR.

Doc. No. _____ ; Notary Public - Province of Benguet
Page No. _____; NPPC No. 18-NC-0444 – Until December 31, 2020
2/F Lumiqued Bldg., JC 179 Km. 5 Pico, La Trin., Beng.
Book No. _____ ;
PTR NO. 6316871, January 3, 2020
Series of 2020.
IBP LIFETIME MEMBER NO. 017081, Baguio-Benguet
ROLL NO. 68089; Page No. 132; Book No. XXIX, May 26, 2017