Republic of the Philippines)

Caloocan City ) S.S.

AFFIDAVIT OF ACKNOWLEDGEMENT

I, _________________________________, of legal age, Filipino, single with

residence address at ____________________________________________ under oath,
hereby depose and state that:

1. I am the biological father of _________________________ who was born on

_______________ in ____________________;

2. The biological mother of my child is _______________________;

3. The fact of birth of my child ____________________________, was duly recorded

at the Local Civil Registry Office of _________________ under Registry No.
__________________;

4. I hereby acknowledge and recognize ___________________ as my child and legal

heir;

5. As father of my acknowledged child, I will include him/her as my beneficiary in my

SSS/Philhealth membership;

6. I am executing this affidavit to attest to the truth of the foregoing facts and for
whatever legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hands this _____ day of

____________ 2022 at Caloocan City, Metro Manila.

With my consent
to use the surname of the father
of my child:

__________________________ _________________________
Mother Affiant/Father

SUBSCRIBED AND SWORN to before me on this ________________ at

__________________________, affiants exhibiting to me their Gov’t issued ID which the
control number were indicated below their respective names.

Doc. No. ______;

Page No. ______;
Book No. ______;
Series of 2022.