REPUBLIC OF THE PHILIPPINES)

PROVINCE OF AKLAN )S.S.

MUNICIPALITY OF KALIBO )
x-----------------------x

AFFIDAVIT TO USE SURNAME OF FATHER (AUSF)

I, ___________________________, of legal age, single, Filipino, and a resident

of Tambak, New Washington, Aklan, after having been duly sworn to in accordance
with law, do hereby depose and say:

1. I am the father of (NAME OF CHILD);

2. He was born on January 16, 2020 at ___________________________, Mabini,

Kalibo, Aklan;

3. That I hereby allow (CHILD) to use my surname, ________________________

and be refelected in his Certificate of Live Birth, in accordance with RA 9255;

4. The birth was recorded under Registry No. _______________ on

_________________;

5. That I execute this affidavit to attest to the truth of the above facts in
compliance with the provisions of Republic Act No. 9255 and its Revised
Implementing Rules and Regulations; and for all legal intents and purposes;

IN TESTIMONY WHEREOF, I have hereunto set my hand this January 17, 2020
at Kalibo, Aklan, Philippines.

_________________________
Affiant

SUBSCRIBED AND SWORN to before me this January 17, 2020 at Kalibo, Aklan,
affiant exhibiting his ____________________________, issued at New Washington,
Aklan on 01/17/2020, I certify that I personally examined the affiant and that he
voluntarily executed the foregoing affidavit and understood the contents.