R. A. NO. 9255 Form No. 1 Registry No.

_________________________
(Revised March 2016)

Republic of the Philippines)

Cebu City, Cebu ) S.S.

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, __________________________, of legal age, single, Filipino, and a resident of Sitio

Kalubihan, Banawa, Cebu City, Philippines, after having been duly sworn to in accordance
with law, hereby depose and state that:

1. I am seeking to use the surname of _______________ in

a) ( ) my Certificate of Live Birth/Report of Birth, pursuant to R. A. No. 9255 and
its revised IRR
b) (X) the Certificate of Live Birth/Report of Birth of ______________________________
who is my illegitimate child/ward, pursuant to R. A. No. 9255 and its Revised
IRR.

2. She was born on AUGUST 13, 2018 at Vicente Sotto Memorial Medical Center, B.
Rodriguez St., Cebu City, Philippines;

3. I am filing this AUSF at the LCRO/PFSP of CEBU CITY, CEBU, PHILIPPINES in

accordance with R. A. 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.

IN WITNESS WHEREOF, I have hereunto set my hand this 16 th day of August 2018 at
Cebu City, Philippines.

___________________________________
Name of Mother- Affiant

SUBSCRIBED AND SWORN to before me this 16 th day of August 2018 at Cebu City,
Philippines, affiant exhibited to me her respective competent evidence of identity written
below her name.

Doc No. ____

Page No. ___
Book No. ___
Series of 2018.