Republic of the Philippines )

City of San Fernando )S.S.

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AFFIDAVIT OF PATERNITY AND FILIATION

I, _____________, of legal age, Filipino citizen, and a resident of Brgy.
Pagdaraoan, City of San Fernando, La Union, after first being duly sworn to on oath in
accordance with law, hereby depose and state that:

I am the biological father of _________________, a minor, who was born on

September 18, 2015 at Ilocos Training Regional Medical Center (ITRMC), San Fernando
City, La Union. Her mother, __________, is my common law wife and we have been
cohabiting for more than sixteen (16) years without the benefit of marriage;

That in the Certificate of Live Birth of my daughter _________, her middle name
and surname were that of her mother, being SANTOS and DELA CRUZ, respectively,
and the personal details corresponding to that of her father were not filled up, considering
that I was not able to attend to my wife when she gave birth to our daughter ________,
hence, I was also not able to sign the acknowledgment of paternity and filiation in my
daughter’s Certificate of Live Birth;

That I am executing this affidavit acknowledging _________ as my natural and

biological daughter, and to have her use my surname which is “CASTRO”, and to have
her name changed from __________ to _______________ in her Certificate of Live Birth
issued by the Local Civil Registrar of San Fernando City, La Union and the Philippine
Statistics Authority (PSA), and for all legal intents and purposes;

I likewise execute this Affidavit to attest to the truthfulness of the above-narrated

facts.

IN WITNESS WHEREOF, I hereby affix my signature this 25 th day of September

2019 at San Fernando City, La Union.

______________________
Affiant
ID No. ________________

SUBSCRIBED AND SWORN TO before me this 25 th day of September 2019 at

San Fernando City, La Union, affiant having personally appeared before me and
exhibiting to me his Identification Card, with picture, which I consider as competent
evidence of his identity.

Doc. No. ____;

Book No. ____;
Page No. _____;
Series of 2019.