RA 9255 Form No.

1
Republic of the Philippines) ___________________
Registry.:No________________
AFFIDAVIT TO USE THE SURNAME OF THE FATHER
I, ______________________________, of legal age, ______________, and a resident of
(Affiants Name) (Citizenship)__________________________, after having been duly
sworn in accordance with
(Complete Address)
law, do hereby declare that:
1. I am the father of _________________
(name of child)
2. He/She was born on ____________________
(date of birth)
at ____________________
(place of birth)
,Kuala Lumpur Malaysia on _________________________
(date of birth)
3. The birth was recorded under Registry Number ___________
on ___________________.4. I hereby allow ____________________
(name of child)
to use my surname in accordance with RA9255
.
5. In support hereof, I submit the attached private handwritten instrument including
the followingsupporting documents:
(Use additional sheets if necessary.)
a) _________________________________________ b)
_________________________________________ c)
_________________________________________ 6. I am filing this affidavit at the LCRO of
____________City in accordance with RA 9255 and itsImplementing Rules and
Regulations.7 . I hereby certify that the statements made herein are true and correct to the best of my
knowledgeand belief.8. In truth whereof, I have hereunto affixed my signature this ____ day
of _________, 20__.
_______________________________
(Signature over printed name of Affiant)
SUBSCRIBED AND SWORN
to before me this _______day of _________, 20__ in the City of ____________________,
affiant exhibiting his Community Tax Certificate NO.: __________ issued on

(affix official seal here)

City Civil Registrar