Embassy of the Philippines )

Consular Section ) S. S.
Ottawa )

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

l, , , a
(Affiant's name) (Citizenship) (Age)

resident of , after having been duly sworn

in accordance with law, hereby declare that:

1. I am seeking to use the surname in:

a) ( ) Certificate of Live Birth I Report of Birth, pursuant to R.A. No. 9255 and its
Revised IRR.

b) ( ) the Certificate of Live Birth/Report of Birth of . _

(Complete name of child)
who is my , pursuant to R.A. No. 9255.

2. I /He/She was born on at --------

(Date of Birth) (Municipality) (Province) (Country)

3. My /The birth was recorded under Registry No. on, _

4. The Affidavit of Admission of Paternity or the Private Handwritten Instrument was recorded
under Registry No. on _
( Registry No.) (Date of Registration)

at the Local Civil Registry Office/ Philippine Foreign Service Post (PFSP) of the Embassy of the
Philippines, Ottawa, Ontario, Canada.

5. I am filing this AUSF at the LCRO /PFSP, Embassy of the Philippines, Ontario, Canada.

6. I hereby certify that the statements made herein are true and correct to the best of personal
knowledge and belief.

Affiant further sayeth naught.

(Signature over Printed Name of Affiant)

Passport No. _
Issued on----------

SUBSCRIBED AND SWORN to before me this__of ,20_, affiant exhibiting to

me his/her Philippine/Canadian passport indicated above.

Doc No. __
Page No.__
Book No.__
Series of__
O.R.No. __
Service No. __