Republic of the Philippines )

Province of Tarlac ) S.S.

Municipality of Capas )

AFFIDAVIT OF ACKNOWLEDGEMENT OF PATERNITY

I, MARK D. ARCEO, of legal age, Filipino and currently residing at Brgy. San
Juan, Concepcion, Tarlac, after having been duly sworn to in accordance with law,
hereby depose and state: THAT-

1. I am the biological father of the minor SAMANTHA KATE CAPAN ARCEO,

who was born on OctoMay 3, 2021, at the Tarlac Provincial Hospital, Tarlac City, to
her mother Richelle Y.Capan;

2. At the time of birth of my daughter Samantha Kate, I wam not legally married to
her biological mother, RICHELLE YUSON CAPAN;

3. I hereby acknowledge my paternity/filiation of my minor illegitimate child,

SAMANTHA KATE CAPAN ARCEO;

4. I am giving my consent for my child to use my surname and that the same be
reflected in her birth certificate;

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

IN WITNESS WHEREOF, I have hereunto set my hand this 21st day of May
2021, in Municipality of Capas, Tarlac, Philippines.

MARK D. ARCEO
Affiant

SUBSCRIBED AND SWORN TO before me this 21st day of May 2021, in the
Municipality of Capas, Tarlac, Philippines, the affiant having satisfactorily established
his identity to me by exhibiting to me his Driver’s License with Lic. No. C11-16-005800,
bearing his picture and signature, as proof of his personal identity.

Doc No. _____; ATTY. CONRADO G. DEL ROSARIO

Page No. ____; Notary Public – Province of Tarlac
Book No. ____; MacArthur Highway, Capas, Tarlac
Series of 2021. Commission Expires on December 31, 2021
IBP No. 1067247/01-03-21/Tarlac Chapter
PTR No. 3227665/01-03-21/Capas, Tarlac
Roll No. 421013; Book 17; Page 213