Republic of the Philippines)

________________________ ) S.S.

Registry No. ___________

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, Juan Dela Cruz of legal age, Filipino, and a resident of Brgy. East Agno,
Pangasinan, after having been duly sworn to in accordance with law, do hereby
declare that:

1. I am seeking to use the surname Dela Cruz in my Certificate of Live

Birth, pursuant to R.A. 9255.

2. I was born on December 1, 2000, at Brgy. Puti, Datu, Philippines.

3. My birth was recorded under registry number 2000-123 on December 27,

2000.

4. The Affidavit of Acknowledgment of Paternity was recorded under

Registry No. 2000-123 on December 27, 2000, at LCRO of Datu Puti.

5. In support hereof, attached hereto is my Certificate of Live Birth with

Affidavit of Acknowledgment of Paternity under Registry No. 2000-1231 and.

7. I am filing this affidavit at the LCRO of Municipality of Datu, Puti, in

accordance with RA No. 9255 and its Implementing Rules and Regulations.

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

In witness whereof, I have hereunto affixed my signature this ____day of

_____________, 2023.

JUAN DELA CRUZ

Affiant

SUBSCRIBED AND SWORN to before me this _______day of

___________, 2023 in the city/municipality of ___________________, affiant
exhibiting his _______________with No. _______________ issued at
________________________on _________________ as competent proof of his
identity.
1
Annex “A” - Certificate of Live Birth with Affidavit of Acknowledgment of Paternity under
Registry No. 2000-123
Doc. No. ___________
Page No. ___________
Book No.___________
Series of 2023