AFFIDAVIT OF PATERNITY AND USE OF FATHER’S SURNAME

Ricky M. Mansueto
I, ____________________ of legal age, 31_______ citizen, and presently residing at
3 Carlos Comp. P Rosales St Brgy Sta Ana Pateros MM
___________________________________________, after having been duly sworn to in

accordance with law, do hereby depose and say:

Xyfhler Nique Ripalda

1. That I am the biological father of ____________________________________;

Xyfhler Nique Ripalda

2. That my child ______________________________ was born on
September 5, 2010
____________________ at
Pateros
__________________________________________;

3. That the facts of birth of my child were duly registered at the

_______________________________________________________________;
Municipality of Pateros

Xyfhler Nique Ripalda

4. That being the father of _____________________, I hereby acknowledge and recognize
Xyfhler Nique Ripalda
___________________________________ as my child and legal heir;

Xyfhler Nique Ripalda

5. That I am allowing my child _______________________________ to use my
surname to be his/her surname in his Certificate of Live Birth; and

6. 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 have hereunto set my hand this __ day of March

______ at

____________________.

Ricky M. Mansueto
Affiant (Signature Over Printed Name)

SUBSCRIBED AND SWORN to before me this ___ day of ______ in the

____________, affiant exhibiting to me his competent evidence of identity by way of
___________________ issued at ______________________ on ________________.

Doc No. : _____

Page No.: ______
Book No.: ______
Series of Notary Public