Republic of the Philippines}

Cebu City }

AFFIDAVIT OF TO USE THE SURNAME OF THE FATHER

       I, , of legal age, and presently residing at Looc, Mandaue City, after having been duly sworn
to in accordance with law, depose and state:

1. That I am the biological father of

2. That the biological mother of my child

3. That my child on June 14, 2015 at Mandaue City.

4. That the facts of birth of my child, duly registered at the Office of the Civil Registrar of
Mandaue City.

5. That I, , being the father had acknowledged and recognized her as my child and legal
heir.

6. That I am allowing my child, to use my surname, to be his surname, in her Certificate of

Live Birth.

7. That my child shall be known as

8. That I execute this Affidavit to attest the truth of the above facts for whatever legal
intents and purposes it may serve and in compliance with the provision of Republic Act
No. 9255.

IN WITNESS WHEREOF, I hereunto affixed my signature this 17 th day of February, 2019

at Mandaue City, Philippines.

With my consent
To use the surname
of the father of my child
SUBCRIBED AND SWORN to before me this 17th day of February, 2019 in the City of
Mandaue, Philippines, affiants exhibited to me their identification documents as shown above.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2019.