R.A No. 9255 Form No.

1
(Revised March 2016)
Registry No.
REPUBLIC OF THE PHILIPPINES )
CITY OF NAGA ) SS

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, JANICE ROMAGOS TAMAYO Filipino Single 20

(Name of mother, or guardian in the absence of the mother) (Citizenship) (Civil Status) (Age)
and a resident of Poblacion, Talisay City, Cebu, Philippines after having been duly sworn to in
accordance with law do hereby declare that:

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

a. my Certificate of Live Birth/ Report, pursuant to R.A No. 9255

b. the Certificate of Live Birth/Report of Birth of JOHN CARLO TAMAYO ALECER

who is my illegitimate child/ward, pursuant to R.A. 9255

2. He was born on May 29, 2022 at Cebu South Medical Center, San Isidro, Talisay City ,
Cebu, Philippines

3. The birth was recorded under Registry No. __________ on ________ (if applicable);

4. The child is acknowledged by the father AT THE BACK OF COLB, evidencing his paternity
over me;

5. I am submitting herewith the following documents, showing the father`s paternity over the child,
viz:

a.) Immunization Card

6. I am filing this affidavit at the LCRO of TALISAY CITY, CEBU in accordance with R.A. No.
9255 and its Revised Implementing Rules and Regulations;

7. I hereby certify that the statement made herein are true and correct to the best of my knowledge
and belief;

IN TRUTH WHEREOF, I have hereunto affixed my signature on this ____ day of

________________ in City of Naga, Cebu, Philippines.

JANICE ROMAGOS TAMAYO

(Name of Mother-Affiant)
(Signature over printed name)

SUBSCRIBED AND SWORN TO before me this _______ day of _______________ in

City of Naga, Cebu affiant exhibiting her CTC 18643921 issued at Talisay City, Cebu on May 30,
2022. I certify that I personally examined the affiant and that she voluntarily executed the foregoing
affidavit and understood the contents thereof.

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Republic of the Philippines )

NAGA CITY, CEBU ) S.S.
X------------------/
 JOINT AFFIDAVIT

We, CHIQUE ABELLANA AND JUSTINE PEPITO Filipinos, of legal ages, and both
residents of Talisay City, Cebu; after having been duly sworn to in accordance with law, do hereby
depose and say:

a) That we very well and personally know JOHN CARLO TAMAYO ALECER who was born
on May 29, 2022 at Cebu South Medical Center, Talisay City Cebu, son of Janice R. Tamayo
and Stepen John E. Alecer;

b) That due to failure to follow-up of the parents, the circumstances regarding the birth of the said
child were not reported to the Office of the Local Civil Registrar of Talisay City, Cebu;

c) That we used to visit the home of the said person during their family occasions, hence, we
possess personal knowledge as to the circumstances of the birth of their children;

d) That we are not related to any of the spouses by consanguinity or affinity;

e.) That we are executing this affidavit in order to state under oath the true circumstances
surrounding the birth of said JOHN CARLO TAMAYO ALECER who and to support the same
their application for late registration of birth with the aforementioned office.

IN WITNESS WHEREOF, we have hereunto affixed our signatures this ____ day of
_________ at Naga City, Cebu, Philippines.

CHIQUE ABELLANA JUSTINE PEPITO

Driver’s License: G01-04-311130 CTC: 186714312

SUBSCRIBED AND SWORN TO before me this ____ day of __________ at the City of
Naga, Cebu. Affiants who exhibited to me their government issued identification card as reflected
below their signatures as a competent proof of their identity.

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