R.A. No. 9255 Form No.

1
(Revised March 2016)

Registry Number________
Republic of the Philippines)
City of Malaybalay)SS

AFFIDAVIT TO USE THE SURNAME OF FATHER

I,____________________________________,___________________, ___________________, ________________

Affiant`s Citizenship Civil Status age
years old, a resident of __________________________________________________________________________
Complete address
after having been duly sworn to accordance with law, hereby declare that.

1. I am seeking to used the surname_________________________________________ in

a. my Certificate of Live Birth/ Report of Birth, pursuant to R.A. No. 9255.
b. the Certificate of Live birth/ Report of Birth of________________________________________
(Complete Name of Child)
who is my _________________________________________, pursuant R.A. No. 9255.
(Relationship of the Affiance to the Child)
2. He was born on_________________________________at ____________________________________
(Date of Birth) (Municipality)
______________________________________________________________________________________
(Province) (Country)
3. The birth was recorded under Registry No.________________on________________________( if applicable)
(Registry No) (Date of Registration)

4. The Public Document or the Private Handwritten Instrument was recorded under Registry No_________ on
_________________________________________________________ at the Local Civil Registry Office (LCRO)/
(Date of Registration)
Philippine Foreign Service Post(PFSP) of ____________________________________________ (if applicable).
(Municipality) (Province) (Country)
5. I am filing this AUSF at the LCRO of_________________________________________ in accordance with
(Municipality) (Province) (Country)

R.A. No. 9255 and its Revised Implementing Rules 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__________day of___________________, 20_______ at
______________________________________________________.

_________________________________
Signature over the printed name of Affiant

SUBSRIBED AND SWORN to before me this______day of___________________in the city of

Malaybalay, Bukidnon, affiant exhibiting his__________________________issued at
_______________________________on_______________________. I certify that I personally examined the
affiant and that he/she voluntarily executed the foregoing affidavit and understood the contents thereof.

_______________________
Notary Public
Doc. No._________________________
Page No._________________________
Book No._________________________
Series of_________________________