Republic of the Philippines)

PROVINCE OF BOHOL ) S.S.

City of Tagbilaran )
x--------------------------------------------x

AFFIDAVIT TO USE THE SURNAME OF FATHER

I, EMERITA DUMANDAN NAQUILA, Filipino citizen of legal age, single, and

a resident of Lucob, Calape, Bohol, Philippines, after having been duly sworn to in
accordance with the law, do hereby depose and state that:

1. I am seeking to use the surname “ROA” in the Certificate of Live Birth/Report of

Birth of “KLYNTH JOHN NAQUILA ROA” who is my illegitimate son pursuant
to R.A. No. 9255 and its revised IRR.

2. He was born on September 10, 2022 at Gov. Celestino Gallares Memorial

Hospital, Tagbilaran City, Bohol, Philippines;

3. That the birth was recorded under Registry No. ___________ on _____________;

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

was recorded under Registry No. __________________ on ___________ at the
Local Civil Registrar’s Office of Tagbilaran City, Bohol, Philippines;

5. I am filing this Affidavit to Use Surname of Father at the Local Civil Registrar’s
Office of Tagbilaran City, Bohol, Philippines in accordance with R.A. No. 9255
and its revised IRR;

6. I am executing this affidavit to attest to the truth of the foregoing facts and for
whatever legal purpose it may serve.

IN WITNESS WHEREOF, I hereunto affixed my signature this 19th day of

August 2022 at Tagbilaran City, Bohol, Philippines.

EMERITA DUMANDAN NAQUILA

Affiant
TIN: 722-852-051-000

SUBCRIBED AND SWORN to before me this 12th day of September 2022 at

Tagbilaran City, Bohol, Philippines. Affiant exhibited to me her identification document
as shown above.

ATTY. THEA IVORY B. PARRAS

0005-H Redondo Street, Manga District, Tagbilaran City, Bohol
NOTARY PUBLIC until December 31, 2023
PTR No. 1029748, May 16, 2022; CY 2022
NCS No. 2022-43; TIN: 473-454-415-000
IBP Membership No. 210082; May 16, 2022 Roll No. 77016, 05/06/22
MCLE Compliance (NEW LAWYER)
For the City of Tagbilaran and Other Municipalities of Bohol
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 2022.