No. 9255 Form No.

1
(Revised March 2016)
Republic of the Philippines
Province of Negros Occidental
City of Kabankalan

Republic of the Philippines) Registry Number: __________

City of Kabankalan) S.S

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, ANELICA BIÑAS ANECITO, FILIPINO, SINGLE, 29 years old, a resident of BRGY

CAMANSI, KABANKALAN CITY, NEG. OCC. after having been duly sworn to in accordance
with law, do hereby declare that:

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

a. My Certificate of Live Birth/Report of Birth, pursuant to R.A. No. 9255 and
its Revised IRR.
b. The Certificate of Live Birth/Report of Birth of DANIELLA ANECITO
ALIPATO
2. He/She was born on AUGUST 29, 2022 at BRGY 9, KABANKALAN CITY.
3. My/The birth was recorded under Registry No. _______________ on _____________.

4. The Affidavit of Admission of Paternity (AAP) or the Private Handwritten Instrument

(PHI) was recorded under Registry No. ______________ __ on ________________
at the Local Civil Registry Office (LCRO) / Philippine Foreign Service Post (PFSP)
of ____ ______.

5. I am filing this AUSF at the LCRO / PFSP of KABANKALAN CITY in accordance

with R.A. No. 9255 and its Revised Implementing Rules and Regulations (IRR).

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

7. In witness whereof, I hereby affix my signature on this 9TH day of MAY, 2023 at
KABANKALAN CITY, NEGROS OCCIDENTAL.

ANELICA BIÑAS ANECITO

Signature over Printed Name of Affiant

SUBSCRIBED AND SWORN to before me this 9TH day of MAY 2023 in KABANKALAN CITY,
NEGROS OCCIDENTAL affiant exhibiting his/her 14259335 issue 05-03-2023 on
KABANKALAN CITY. I certify that I personally examined the affiant and that he/she voluntarily
executed the foregoing affidavit and understood the contents.

MONALISA D. TABUJARA
ACTING CITY CIVIL REGISTRAR/RO IV
Administer Officer