REPUBLIC OF THE PHILIPPINES )

CITY OF ____ ) S.S.

PROVINCE OF ____ )

AFFIDAVIT OF DECLARATION
I, ____, ___ years of age, Filipino, and presently residing at _____, after
having been duly sworn to in accordance with law, do hereby depose and say:

1. That I am the natural child of my biological parents, namely ___ and

___;

2. That my parents lived together as husband and wife; however, they

separated when I was about ___ years old, more or less;

3. That I have ___ other siblings, all born from my parents, I being their
eldest, and we were all acknowledged by our father ____, and were
allowed to use his surname;

4. As such, I used the surname “___” in my school records and other official
documents, up until I started using the surname of my spouse, which is
“____”;

5. That my parents never caused the registration of my birth with the Civil
Registrar due to neglect and lack of knowledge;

6. That in order to cause the late registration of the fact of my birth with the
Civil Registrar, I need to secure other pertinent documents such as school
records that would indicate my usage of the surname “____”;

7. As such, I am executing this Affidavit to narrate the facts and

circumstances surrounding my maiden surname “____”, declaring and
affirming the truth and veracity of the foregoing, and for all legal purposes
that this may serve.

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

____, ____ in the ____, Province of ____.

___________________________
Affiant

SUBSCRIBED AND SWORN to before me this ___ day of _______ _____

in the ___________, Province of _____.