REPUBLIC OF THE PHILIPPINES)

__________________________ )S.S.

AUTHORITY TO USE THE SURNAME OF THE FATHER

I, ______________________________, of legal age, Filipino, single and with residence at

______________________________________________, after having been duly sworn to in accordance
with law, do hereby depose and state that:

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

my Certificate of Live Birth, pursuant to R.A. 9255 and its Revised Implementing Rules
and Regulations;
the Certificate of Live Birth of my _________, ________________________________,
R.A. 9255 and its Revised Implementing Rules and Regulations;

2. I/He/She was born on _______________ in _________________________;

3.
4. My/The birth was recorded under registry no. _______________ on ________________;
(if applicable)

5. The affidavit of admission of paternity or private handwritten instrument was recorded under
registry no. ___________ on ______________ before the Local Civil Registry Office of
__________________________________; (if applicable)

6. I am filing this document before the Local Civil Registry Office of ________________________
in accordance with R.A. 9255 and its Revised Implementing Rules and Regulations;

7. I hereby certify that the aforementioned statements are true and correct to the best of my
knowledge and belief.

IN WITNESS WHEREOF, I have personally affixed my signature on __________________ at

______________________________, Philippines.

__________________________________
Affiant

SUBSCRIBED AND SWORN to before me this ____ day of ______________ at

____________
_____________________. Affiant hereby affixed his/her __________________________________, and
I certify that I personally examined the affiant and that he/she has voluntarily the foregoing affidavit and
understood the contents thereof.

Doc No. ____;

Page No. ___;
Book No. ___;
Series of _______.