Republic of the Philippines)

PROVINCE OF BOHOL ) S.S.

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

AFFIDAVIT TO USE THE SURNAME OF FATHER

I, FRANCIS B. BLANCO, Filipino citizen of legal age, single, and a resident of

Mansasa, Tagbilaran City, 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 “____________” in my Certificate of Live

Birth/Report of Birth pursuant to R.A. 9255 and its revised IRR

in the Certificate of Live Birth/Report of Birth of “______________” who is my

illegitimate son pursuant to R.A. No. 9255 and its revised IRR.

2. He/she was born on ____________ at __________, 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 4 th day of August

2022 at Tagbilaran City, Bohol, Philippines.

FRANCIS B. BIOCO
affiant
Driver’s License: N02-06-030711

SUBCRIBED AND SWORN to before me this 4th day of August 2022 at

Tagbilaran City, Bohol, Philippines. Affiant exhibited to me his 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.