Republic of the Philippines

__________________City, Philippines

) S.S.

x--------------------------x

AFFIDAVIT TO USE THE SURNAME OF THE

FATHER/ACKNOWLEDGMENT

I, ___________________, of legal age, Filipino citizen, and a resident of

___________________________________________________________, after having been
duly sworn to in accordance with law, do hereby depose and say:

1. That I am the biological father of _________________________________ ;

2. That

the
biological
mother
_________________________________;

of

the

child

is

3. That

my child _________________________________ was born on

_________________________________at _________________________________;

4. That

I, _________________________________, being the father of

_________________________________
,
hereby
acknowledged
and
recognized him as my child and legal heir;

5. That I am allowing my child _________________________________ to use my

surname _________________________________ to be his surname in his
Certificate of Live Birth and Certificate of Birth;

6. That I execute this affidavit to attest to the truth of the above facts in
compliance

with

the

provisions

of

Republic

Act

No.

9255.

IN WITNESS WHEREOF, I have hereunto set my hand this

________________________ at _________________________________, Philippines.

_________________________________
Affiant

SUBSCRIBED AND SWORN to before me this _______________________in

the City of _________________________________, Philippines, affiant exhibiting to
me
his
competent
evidence
of
identity
by
way
of
_________________________________________

Doc No. : _____

Page No.: ______
Book No.: ______
Series of 2016