R.A. NO. 9255 Form No.

1
Registry Number __________________
Republic of the Philippines )
Province of Cavite )S.S.
Trece Martires City )

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, _________________, ______ years of age, Filipino citizen, single, ___________, after having
been duly sworn to in accordance with law, do hereby declare that:

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

a) my Certificate of Live Birth/Report of Birth, pursuant to R.A. 9255 and its Revised IRR.
b) the Certificate of Live Birth/Report Birth of ______________________
√
who is my ____________________.

2. He/She was born on ___________________ at __________, Philippines.

3. The birth was recorded under Registry Number _________ on __________;

4. The Affidavit of Admission of Paternity of the Private Handwritten instrument was recorded
under Registry No. (______________) on (_________) at the Local Civil Registry Office
(LCRO)/Philippine Foreign Service Post (PFSP) Trece Martries City, Cavite, Philippines;

5. I am filling this AUSF at the LCRO/PFSP of Trece Martires City, Cavite, Philippines, in
accordance with R.A. 9255 and Its Revised Implementing Rule 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 6 th day of December 2021 at Trece
Martires City, Cavite, Philippines.

_________________________
Signature Over Printed name of Affiant

SUBSCRIBED AND SWORN to before me on this 6th day of December 2021 in Trece Martires City,
Cavite, Philippines, affiant exhibiting her PhilHealth Identification bearing the number ____________
competent proof of her identity.

I certify that I personally examined the affiant and that she voluntarily executed the foregoing
affidavit and understood the contents thereof.

Doc. No. : ______

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