R.A. No. 9255 Form No.

2A
( March 2016)

Republic of the Philippines

CITY OF TARLAC
Province of Tarlac

OFFICE OF THE CITY CIVIL REGISTRAR

aZRa

CERTIFICATE OF REGISTRATION

TO WHOM IT MAY CONCERN:

This is to certify that the Affidavit To Use The Surname of the Father (AUSF)
executed by ________________________________________________________________ on ___________________
at Tarlac City, Tarlac was recorded in the Register of Legal Instruments under Registry
Number 2023-_________ on _________________________ in the Certificate of Live Birth of:

Name of Child
Date of Birth
Place of Birth
Name of Father
Name of Mother

Registry Number of the COLB 2023-

Issued this _____ day of _______________ 2023 at Tarlac City

ARMIN LEONARDO F. IBARRA

City Civil Registrar