RA 9255 Form No.

1
(Revised March 2016)
Registry Number :_____________

REPUBLIC OF THE PHILIPPINES)

TALISAY CITY ) SS

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, JENNETTE SALINAS TAPIC, FILIPINO , SINGLE ,30 and a

(Name of mother, or guardian in the absence of the mother) (Citizenship) (Civil Status) (age)

resident of HOLY CHILD TABUNOC, TALISAY CITY, CEBU, PHILIPPINES, after having been
duly sworn to in accordance with law do hereby declare that:

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

(Father’s Surname)

a. my Certificate of Live Birth / Report of Birth, pursuant to R.A. No. 9255

b. X the Certificate of Live Birth / Report of Birth of N-JHAY TAPIC TABUJARA who is my
illegitimate child/ward, pursuant to R.A. 9225. (Full name of child as written in the COLB)
2. He/She was born on APRIL 29, 2017 in LYING-IN CLINIC, TABUNOK, TALISAY CITY, CEBU;
(Date of birth) (Place of birth)
3. The birth was recorded under Registry No._____________on___________(if applicable)
4. The child is acknowledged by the father AT THE BACK OF COLB ,
evidencing his paternity over me; (Full name of child as written in the COLB)
5. I am submitting herewith the following documents, showing the father’s paternity over
the child, viz:
IMMUNIZATION CARD
a.) ____________________________________
b.) ____________________________________
6. I am filing this affidavit at the LCRO of CITY OF TALISAY in accordance with R.A.
No.9255 and its Revised Implementing Rules and Regulations.
7. I hereby certify that the statement made herein are true and correct to the best of my
knowledge and belief.
8. In truth whereof, I have hereunto affixed my signature on this 12th day of May 2017 in
Talisay City, Philippines.

JENNETTE SALINAS TAPIC

_____________________________
(Name of mother Affiant)
(Signature over printed name)

SUBSCRIBED AND SWORN TO before me this 12 th day of May 2017 in the

city/municipality of CITY OF TALISAY, CEBU affiant exhibiting his/her CTC NO. 07904220
issued at CITY OF TALISAY, CEBU on 5.5.17. I certify that I personally examined the affiant
and that he/she voluntarily executed the foregoing affidavit and understood the contents thereof.

Doc. No. 65 ATTY. ROMEO C. VILLARANTE

Page No. 13 NOTARY PUBLIC UNTIL DEC. 31, 2018
Book No. 03 NOT. COM. 2016-14-EJ, 01-10-2017
Series of 2017. RTC-TALISAY CITY, CEBU, IBP LFTM#02872
PTR NO. 2712731, 1-3,2017
ATTORNEY’S ROLL NO. 39674
2/F ALFAFARA BLDG, HIGHWAY, TABUNOK
TALISAY CITY, CEBU
TIN NO. 149-647-064
.