AFFIDAVIT OF ACKNOWLEDGMENT

AND USE OF FATHER’S SURNAME

I, RODEN A. BAUTISTA, of legal age, Filipino citizen, married, and

presently residing at P-12-21, 12th/3rd Streets, Brgy. 183, Villamor, Pasay City,
after having been duly sworn in accordance with law, do hereby depose and say:

1. That I am the biological father of Justin Mendoza;

2. That my child Justin Mendoza was born on 17 October 2001 in

Mandaluyong City;

3. That the facts of birth of my child were duly registered at the Office of the
Local Civil Registrar of Mandaluyong City;

4. That being the father of Justin Mendoza, I hereby acknowledge and

recognize Justin Mendoza as my child and legal heir;

5. That I am allowing my child Justin Mendoza to use my surname to be his

surname in his Certificate of Live Birth; and

6. 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 __ day of

______________ 2019 in Pasay City.

RODEN A. BAUTISTA
Affiant

Doc. No.___:
Page No.___;
Book No. ___;
Series of 2019.