Republic of the Philippines)

Province of ______ ) S.S.

Municipality of ______ )

AFFIDAVIT OF ACKNOWLEDGMENT
{ADMISSION OF PATERNITY}

I, ____________, of legal age, single and a resident of BARANGAY,

MUNICIPALITY, PROVINCE, after having been sworn to in accordance
with the law, hereby depose and state that:

1. I am the biological father of

__________ who was born on August 11, 2011 in Eastern Visayas
Regional Medical Center, Tacloban City;

2. When________ was born, I was not legally married to her mother

_______________;

3. I am a common law husband of _________;

4. I hereby acknowledged paternity over ___________ as I have

signed her unregistered live birth certificate;

5. In pursuant to RA 9255, I have consented to the use of my

surname of the said child, from ___________ to_______________;

6. I have executed this affidavit to attest the truthfulness of the

foregoing statements and to register the birth of my child
________.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

_____________, here in the MUNICIPALITY, PROVINCE, Philippines.

WARFY B. OROPA
Affiant

SUBSCRIBED AND SWORN TO before me in the City of _______________

on this day of _________________, affiant exhibiting before me his
identification document _______________ with number
__________________ which will expire on _____________________.

Notary Public
Doc. No. ___;
Page No. ___;
Book No. ___;
Series of 201__.