REPUBLIC OF THE PHILIPPINES)

STA. CRUZ, OCCIDENTAL MINDORO)S.S.

AFFIDAVIT
(Re: Entries in Certificate of Live Birth)

I, JOCELYN FILEA DOÑA, of legal age, single, Filipino citizen

and with residential address at Alacaac, Sta. Cruz, Occidental
Mindoro, after having been sworn to in accordance with law hereby
depose and say;

1. That I am the mother of JULIA PILEA DOÑA, whom I

gave birth on 24 March 2010 at the Occidental Mindoro
Provincial Hospital, Mamburao, Occidental Mindoro;

2. That at the time I gave birth to my daughter, her father

JONAS MEDINA CALIBOSO acknowledged my
daughter as his daughter also, although the father did not
sign the Certificate of Live Birth to signify his Admission
to Paternity;

3. That I categorically declare under oath that since the birth

of my daughter, her father acknowledges her as his
daughter and gave support up to the present;

4. That this affidavit is hereby set in order to request from

the Civil Registry of Mamburao, Occidental Mindoro to
effect the said acknowledgment and paternity in favor of
JONAS MEDINA CALIBOSO, who have hereunto affixed
his signature, over our daughter JULIA PILEA DOÑA;

5. Further, there was also a typographical error in my

Middle Name as the mother, which should read as
“FILEA” coming from my middle name instead of PILEA

6. That I am executing this affidavit in order to attest to the

truth and the foregoing circumstances behind my
daughter’s true and correct identity and to use the
surname CALIBOSO and any other purposes not contrary
to law;

FURTHER, AFFIANT SAYS NOTHING.

Done this 4th day of February, 2015, Sta. Cruz, Philippines.

 JOCELYN FILEA DOÑA
Affiant
Voter’s ID No. 5111-0012-H0792JFD0000

CONFORME:

JONAS MEDINA CALIBOSO

Father
Voters ID No. 5111-0049-F1184JMC1008-3

SUBSCRIBED AND SWORN TO BEFORE ME, the Presiding Judge of

MTC-Sta. Cruz, Occidental Mindoro, in my capacity as Ex-Officio Notary Public
this 4th day of February, 2015, personally by the affiant showing his ID Card
indicated above as proof of his/her identity.

Doc. No. ____ Hon. JULIETO F. FABRERO

Page No. ____ Presiding Judge &
Book No. ____ Ex-Officio Notary Public
Series of 2014

CERTIFICATION

To Whom It May Concern:

This is to certify that there is no available

Notary Public within the municipality when this
Document was made and executed.

Hon. JULIETO F. FABRERO

MTC Judge