Republic of the Philippines )

City of Dagupan ) S.S.

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

AFFIDAVIT TO USE THE SURNAME OF THE

FATHER/ACKNOWLEDGMENT

I, VICTOR CHIMA AMA, of legal age, Nigerian citizen, and presently

residing at Bolosan District, Dagupan City, Philippines, after having been duly
sworn to in accordance with law, do hereby depose and say:

1. That I am the biological father of AMANDA BERGANTINOS AMA.

2. That the biological mother of the child is ROSELYN DE GUZMAN

BERGANTINOS.

3. That my child AMANDA BERGANTINOS AMA was born on 8

November 2018 at Region 1 Medical Center, Arellano, Dagupan City.

4. That the facts of birth of my child were to be registered at the Office of

the Local Civil Registrar – Dagupan City.

5. That I, VICTOR CHIMA AMA, being the father of AMANDA

BERGANTINOS AMA, hereby acknowledged and recognized her as my child
and legal heir.

6. That I am allowing my child AMANDA BERGANTINOS AMA to use

my surname AMA to be her surname in her Certificate of Live Birth.

7. 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 7th day February
2019 at Dagupan City, Philippines.

VICTOR CHIMA AMA

Affiant
Alien Certificate of Registration
No. G1712008894TV
Issued on 12/13/2017

SUBSCRIBED AND SWORN to before me this ___ day of February 2019 in

Dagupan City by Victor Chima Ama, who has satisfactorily proven his identity to
me through his government-issued ID, which is written below his name, that he is
the same person who personally signed the foregoing instrument before me and
acknowledged that he executed the same.

NOTARY PUBLIC