REPUBLIC OF THE PHILIPPINES)

Tacloban City ) S.S.

x-----------------------x

AFFIDAVIT
I, REY ADARNE VICUÑA, of legal age, Filipino, and presently residing at Brgy.
San Vicente, Alangalang, Leyte, Philippines, after having been duly sworn to in
accordance with law, do hereby depose and say:

1. That I am the biological father of MARY JOY A. VICUÑA;

2. That my child MARY JOY A. VICUÑA was born on October 8, 1995 at

Alangalang, Leyte;

3. That being the father of MARY JOY A. VICUÑA, I hereby acknowledge and
recognize MARY JOY A. VICUÑA as my child and legal heir;

4. That I am allowing my child MARY JOY A. VICUÑA to use my surname to be

her surname in his Certificate of Live Birth; and

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.

IN WITNESS WHEREOF, I set my hand this _____________, at

_____________, Philippines.

REY ADARNE VICUÑA

Affiant

SUBSCRIBED AND SWORN to before me, this _____________, by REY A.

VICUÑA who exhibited her PhilHealth Membership ID No. 23-002260734-6, whom I
have identified through competent evidence of identity.

Doc. No. ______;

Page No. ______;
Book No.______;
Series of 2021.