R.A. No. 9255 Form No.

1
(Revised March 2016)

Registry Number: ____________

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, ________________________________, _________________, _________________, ______ years old, a resident of

(Affiant’s Name) (Citizenship) (Civil Status) (Age)

_________________________________after having been duly sworn to in accordance with law, do hereby declare that
(Complete Address)

1. I am seeking to use the surname _____________________ in:

a. my Certificate of Live Birth/Report of Birth pursuant to R.A. No. 9255 and its Revised IRR

b. the Certificate of Live Birth/Report of Birth of ______________________________________________

(Complete Name of Child)

who is my ______________________________ pursuant to R.A. 9255 and its Revised IRR;

(Relationship of the Affiant to the Child)

2. He/She was born on _______________ at ___________________________________________________________

(Date of Birth) (City/Municipality) (Province/State) (Country)

3. My/The birth was recorded under Registry No. ________________ on ___________________ (if applicable);
(Registry Number) (Date of Registration)

4. The Affidavit of Admission of Paternity or the Private Handwritten Instrument was received under Registry No. _____
on ________________________ at the Local Civil Registry Office (LCRO) of ______________________________/
(Registry No./Date of Registration) (City/Municipality)

Philippine Foreign Service Post __________________________ (if applicable).

(Embassy or Consulate)

5. I am filing this AUSF at the Local Civil Registry Office (LCRO) of _________________________________________/
(City/Municipality)
Philippine Foreign Service Post __________________________ as prescribed by R.A. No. 9255 and its Revised
(Embassy or Consulate)
Implementing Rules and Regulations.

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

IN WITNESS WHEREOF, I hereby affix my signature on this _____ day of _______ 20____ at __________,
___________.

______________________________________
Signature over Printed Name of Affiant

----------------------------------------------------------------------------------------------------------------------------------------------------------------
PHILIPPINE CONSULATE GENERAL) S.S
MILAN, ITALY )

SUBSCRIBED AND SWORN to before me this ______day of _____ in the city/municipality of ______________
affiant exhibiting his/her____________________ issued at __________________on ____________________________.
I certify that I personally examined the affiant and that he/she voluntarily executed the foregoing affidavit and understood
the contents thereof.

_____________________________________
Signature over Printed Name
of the Administering Officer

Doc. No. :___________

Page No. :___________
Book No. :___________
Series of :___________
Fee Paid :___________
O.R. No. :___________
 SWORN ATTESTATION

I, __________________________, __________________ citizen, ________________________

(Affiant’s name) (Citizenship) (Civil Status)

of legal age, with address at __________________________________ after being sworn in accordance with

law, do hereby depose and state that I am the mother/guardian of the affiant in the Affidavit to Use the

Surname of the Father (AUSF) that my child/ward ______________________________________________

is fully aware of the consequences of the use of the surname of his/her father.

IN WITNESS WHEREOF, I hereby hereunto affixed my signature this day of ________________________

_____20____, in __________, ____________.

__________________________________
Signature of Mother/Guardian
over Printed Name

----------------------------------------------------------------------------------------------------------------------------- -------------------

PHILIPPINE CONSULATE GENERAL) S.S

MILAN, ITALY )

SUBSCRIBED AND SWORN to before me this ______day of _____ in the city/municipality of

______________ affiant exhibiting his/her____________________ issued at __________________on
____________________________.

I certify that I personally examined the affiant and that he/she voluntarily executed the foregoing affidavit and
understood the contents thereof.

_________________________________
Signature over Printed Name
of the Administering Officer
Doc. No. :___________
Page No. :___________
Book No. :___________
Series of :___________
Fee Paid :___________
O.R. No. :___________