Registry Receipt No. ______________
R.A. 9255 Form No. 1
(Revised March 2016)
REPUBLIC OF THE PHILIPPINES )
Cebu City ) S.S.
AFFIDAVIT TO USE THE SURNAME OF THE FATHER
I, (NAME OF MOTHER-AFFIANT), Filipino, Single, _____ years old, and a resident of (Address of Affiant), Philippines, after having been duly sworn to in accordance with law do hereby declare that:
1. I am seeking the use of the surname (SURNAME OF FATHER OF CHILD) in:
a. ( ) my Certificate of Live Birth/ Report of Birth, pursuant to R.A. 9255
b. ( X ) the Certificate of Live Birth/ Report of Birth of (NAME OF CHILD USING FATHER'S SURNAME), who is my illegitmate Son/Daughter, pursuant to R.A. 9255
2. He/She was born on (Date of Birth of Child) at (City/Municipality, Province), Philippines;
3. I am filing this AUSF at the LCRO/PFSP of (City/Municipality, Province), Philippines in accordance with R.A. No. 9255 and its Revised Implementing Rules and Regulations;
4. I hereby certify that the statements made herein are true and correct to the best of my knowledge and belief;
5. In truth whereof, I have hereunto affixed my signature this _____ day of (Month) (Year) in (City/Municipality, Province), Philippines.
NAME OF MOTHER-AFFIANT
Affiant
SUBSCRIBED AND SWORN to before me this (Date of Notarization) in (Place of Notarization), Philippines, affiant exhibiting to me his/her valid ID (ID Details) as competent proof of identity and manifested to me that he/she understood the contents thereof.
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of _____.
