REPUBLIC OF THE PHILIPPINES )

PROVINCE OF PANGASINAN )S.S

MUNICIPALITY OF LINGAYEN )

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I SWEET JENESIE V.MIRANDA ,of legal age , Filipino Citizen, single , and resident of #750 Pangapisan
North ,Lingayen , Pangasinan after having been duly sworn to in accordance with law , do hereby declare
and say:

That I am the natural mother of ZYMON ZAC RHAN MIRANDA DE GUZMAN, who was born on
SEPTEMBER 20,2012 at SPECIALIST GROUP OF HOSPITAL AND TRAUMA CENTER , Dagupan City
Pangasinan:

That the biological father of my son named aboved is ANGEL ACE IRIS VINLUAN DE GUZMAN;

That I am seeking the change of surname in the Certificate of Live Birth of my son ZYMON ZAC RHAN
MIRANDA DE GUZMAN;

That ANGEL ACE IRIS VINLUAN DE GUZMAN , being the father of ZYMON ZAC RHAN MIRANDA DE
GUZMAN acknowledged and recognized him as his child and legal heir;

That I am allowing my child ZYMON ZAC RHAN MIRANDA DE GUZMAN to use the surname DE GUZMAN
in his Certificate of Live Birth and now be ZYMON ZAC RHAN MIRANDA DE GUZMAN;

That I am filling this affidavit at the DCRO of Dagupan City , Pangasinan in accordance with R.A No.9255
and it's implementing Rules and Regulations;

That I am executing this Affidavit to attest to the truth of the foregoing facts and for whatever legal
purposes it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 20th day of March 2019 at Lingayen,
Pangasinan.

SWEET JENESIE VENTAYEN MIRANDA

AFFIANT

SUBSCRIBE AND SWORN to before me on the date , year and place above state.