Republic of the Philippines )

Quezon City ) S.S.

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, ANDREA MAE FERNANDEZ, Filipino, single, female, 18 years old, a resident
of ________________________________________after having been duly sworn in
accordance with law, hereby depose and state that:

1. I am seeking to use the surname LANUZA in my Certificate of Live Birth /

Report of Birth, pursuant to R.A. No. 9255 and its Revised IRR.

2. I was born on March 20, 2002 at San Pablo City, Laguna;

3. My birth was recorded under Registry No. _________________ on

_________________;

4. The Affidavit of Admission of Paternity was recorded under Registry No.

_______________________ on ___________________ at
___________________;

5. I am filing this Affidavit to Use the Surname of the Father (AUSF) at the
___________________________ in accordance with R.A. No. 9255 and
its Revised Implementing Rules and Regulations;

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

IN WITNESS WHEREOF, I hereby affix my signature this

_________________________ at Quezon City, Philippines.

ANDREA MAE FERNANDEZ

Affiant

SUBSCRIBED AND SWORN to before me this , at

Quezon City, with affiant exhibiting her __________________________________
which is valid until__________________________________.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2020