Republic of the Philippines )

In the City of San Jose ) S.S.

Province of Nueva Ecija )
x------------------------x

AFFIDAVIT OF MOTHER

I, ___________________________of legal age, and a resident of

___________________________, after having been duly sworn to in accordance with law
hereby depose and state:

1. That I am the mother of ___________________________who was born on

___________________________in ___________________________.

2. That the father of my son, ___________________________, and I are already separated. In

fact, he is already overseas and we have no communication anymore.

3. That the father of my son and I were not married.

4. That in view of the foregoing, I hereby respectfully request that my son use my surname
___________________________ and that he be registered with the name
___________________________.

5. That I further execute this affidavit to attest to the truthfulness of the foregoing narration
of facts and for whatever legal purpose this may serve.

AFFIANT FURTHER SAYETH NAUGHT

IN WITNESS WHEREOF, I have hereunto set my hands this 7th day of August 2023,
hereat San Jose City, Nueva Ecija.

_________________________
Affiant

SUBSCRIBED AND SWORN to before me this 7th day of August 2023, hereat San
Jose City, Nueva Ecija. Affiant exhibited to me her competent evidence of identity bearing her
picture and signature.