REPUBLIC OF THE PHILIPPINES

City Civil Registry Office

Quezon City, Metro Manila

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, Jaynies D. Brion, of legal age, Filipino, with postal and residence address at # 290 Brgy. San
Buenaventura, San Pablo City, Laguna, after having been duly sworn to in accordance with law
hereby depose and say:

1. That I am the biological father of Cyrene;

2. That the biological mother of my child is Cheryll G. Maghirang;

3. That my child Cyrene was born on June 28, 2010 at Quezon City;

4. That I Jaynies D. Brion, being the father of Cyrene hereby acknowledge and recognize
her as my child and legal heir;

5. That I am allowing my child Cyrene to use my surname, Brion to be her surname and
shall be known as Cyrene M. Brion.

6. That I am executing this affidavit to attest to the truth and veracity of the foregoing facts
and for whatever legal intents and purpose it may serve, in compliance with the provision
of Republic Act No. 9255.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 11 th day of July 2010 at
Quezon City, Metro Manila.

Conforme:

_________________________ _________________________
Cheryll G. Maghirang Jaynies D. Brion
Mother Affiant/Father

SUBSCRIBED AND SWORN TO before me this _______________ day of _______________

at Quezon City, Metro Manila affiants exhibiting to me his Community Tax Certificate No.
03645377 issued on 9th July 2010 at Novaliches, Quezon City.

Doc. No.
Page No.
Book No.
Series of 2010