RA 9255 Form No.

1(Devised May 2004)

Republic of the Philippines )

Cainta, Rizal ) S.S. AUSF Registry No. ________

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, MARY KATE KZIHALLE O. LIBRES, Filipino, of legal age, and a resident of

Block 55, Planters, Barangay San Andres, Cainta, Rizal, under oath, do hereby depose
and states, that:

I am seeking for the use of surname in:

a) my Certificate of Live Birth

b) x the Certificate of Live Birth of

MARY JUSZINE L. CACAYORIN who is my daughter;

She was born on January 20, 2024 in Cainta, Rizal;

The birth was recorded under Registry No. at the LCRO of

Cainta, Rizal. (if applicable)

I am filing this affidavit at the LCRO of Cainta, Rizal.

I hereby certify that the statements made herein were true and correct to the best
of my knowledge and belief.

IN WITNESS WHEREOF, I have hereunto set my hand and respective signature

nd
this 22 day of January 2024 at Cainta, Rizal.

______________________________
MARY KATE KZIHALLE O. LIBRES
ID No. 01-026287307-8
Issued by PhilHealth
Affiant

SUBSCRIBED AND SWORN TO before me on the date and at the place above-
written.

Doc. No. ;
Page No. ;
Book No. XXII ;
Series of 2024