REPUBLIC OF THE PHILIPPINES)

CITY OF TAGBILARAN ) S. S.

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, ANDREW PUGOSO, Filipino, of legal age, married and a resident of Bingag, Dauis,
Bohol, after having been sworn in accordance with law, hereby depose and say:

1. That I am the biological father of Mc ANDREI SONGALIA;

2. That the biological mother of my child is EMELIE H. SONGALIA;

3. That my child, Mc Andrei Songalia was born on August 26, 2008 at Bingag, Dauis,
Bohol;

4. That the fact of birth of my child, Mc Andrei Songalia, was duly registered in the
Office of the Local Civil Registrar of Dauis, Bohol;

5. That I, Andrew Pugoso, the father of Mc Andrei Songalia, acknowledged and

recognized him as my child and legal heir in a separate document/birth certificate and allowed
him to use his surname in accordance with law;

6. That my child, Mc Andrei Songalia, will henceforth use the surname of his father,
PUGOSO, to be his surname in his Certificate of Live Birth;

7. That my child shall be known as Mc ANDREI SONGALIA PUGOSO;

8. That I execute this affidavit to attest to the truth of the above facts for whatever legal
intents and purposes it may serve and in compliance with the provision of Republic Act No.
9255.

IN WITNESS WHEREOF, I have hereunto set my hand this 9 th day, of March. 2010, at
Tagbilaran City, Bohol, Philippines.

ANDREW PUGOSO
Affiant

SUBSCRIBED AND SWORN to before me this 9 th day, of March, 2010, at Tagbilaran

City, Bohol, Philippines.

ATTY.THADDEUS JOSE C. ACERO

Notary Public
Until December 31, 2010
Attorney’s Roll No. 23931
PTR # 8393592, 1-4-10, Valencia, Bohol
IBP # 711295, 12-22-09, TIN 126-371-455