Republic of the Philippines )

City of Tayabas ) S.S.

Province of Quezon )
X---------------------------------------------X

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, DONNA DAGSA ABULENCIA, 21 years of age, Filipino, single, with residential
and postal address at Barangay Palale Silangan, City of Tayabas, Province of Quezon,
Philippines, after having been duly sworn to in accordance with law, do hereby declare that:

1. I am seeking to use the surname “BACAY” in the Certificate of Live Birth/Report of

Birth of JARWIN ABULENCIA BACAY who is my natural child, pursuant to R.A.
9255 and its Revised IRR.

2. He was born on March 12, 2019 at Quezon Memorial Center (QMC), Lucena City,
Province of Quezon.

3. The birth was recorded under his Certificate of Live Birth with Registry No. (No
Number) on March 12, 2019.

4. The Affidavit of Admission of Paternity or the Private Handwritten Instrument was

recorded under Registry No. _________ on ______________ at
____________________________________ (if applicable).

5. I am filing this AUSF at the Office of the Civil Registrar of Lucena City, Province of
Quezon, Philippines in accordance with R.A. 9255 and its Revised Implementing Rules
and Regulations

6. I hereby certify that the statements made herein are true and correct to the best of my
knowledge and belief.

IN WITNESS WHEREOF, I hereby affixed my signature this 28th day of March 2022 at
Tayabas City, Province of Quezon, Philippines.

____________________________
DONNA DAGSA ABULENCIA
Declarant

SUBSCRIBED AND SWORN to before me this 28th day of March 2022 in the City of
Tayabas, Province of Quezon, Philippines. The declarant exhibited to me his National Police
Clearance with I.D. No. TRAWUK20220320810266 issued by the Philippine National Police on
March 28, 2022 as competent evidence of her identity.

Doc. No. 392;

Page No. LXXIX;
Book No. II;
Series of 2022.