Republic of the Philippines)

City of _____________ ) SS
x-----------------------------------/

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

            I, JANET HITUTUANE ALCACHOPAS, of legal age, Filipino

citizen, and presently residing at Purok 1, Brgy. Buenavista Bansalan,
Davao del Sur, after having been duly sworn to in accordance with law, do
hereby depose and say:

1. That I am the biological mother of JANELLA ALCACHOPAS.

2. That the biological father of my child is BENJIE GILLEDO

BAYLOSIS.

3. That my child JANELLA ALCACHOPAS was born on July 25,

2013 at SPMC, Davao City;

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

of the Civil Registrar of Davao City;

5. That my child’s father has acknowledged the paternity through an

Affidavit of Admission of Paternity;

6. That I am allowing my child JANELLA ALCACHOPAS to use the

surname BAYLOSIS to be her surname in her Certificate of Live
Birth.

7. That I execute this affidavit to attest to the truth of the above facts
and for my child to use her father’s surname, BAYLOSIS, and that the
same be reflected in my child’s Certificate of Live Birth, pursuant to
RA 9255 and its Revised Implementing Rules.

IN WITNESS WHEREOF, I have hereunto set my hand this ___ day

of _____________ at _____________, Philippines.
 JANET HITUTUANE ALCACHOPAS
Affiant

SUBSCRIBED AND SWORN to before me this _____ day of

____________, at ______________ Philippines, affiant exhibiting to me her
competent evidence of identity PAG-IBIG ID No. 1212-0490-9269.

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