Republic of the Philippines )

City of Manila )

SWORN ATTESTATION

I, JUAN DELA CRUZ, of legal age, Filipino, and with residence at Amurao Street,
Caloocan City, after being sworn in accordance with law, do hereby depose and state that;

1. I am the mother of PEDRO PENDUKO pursuant to R.A. No. 9255;

2. He was born on 25 March 2010 in Sta. Cruz, Manila;

3. The birth was recorded under registry no. 023996 on 20 April 2010 at the Local Civil
Registry Office (LCRO) of City of Manila;

4. I am filing this authority to use the surname of the father at the LCRO of City of Manila in
accordance with R.A. 9255 and its Revised Implementing Rules and Regulations;

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

IN WITNESS WHEREOF, I have hereunto set my hands on this ___ day of __________ 2019
at ______________________.

_______________________
Affiant/Mother

SUBSCRIBED AND SWORN to before me on this ____ day of __________ 2019 at

_________________________, affiant exhibiting to me her COMELEC Voter’s Identification card
with no. 7501-1913E-E1189JDR20000.

Doc No. _____

Page No. _____
Book No. _____
Series of 2019