REPUBLIC OF THE PHILIPPINES)

_________________________________ …..……) s.s.

AFFIDAVIT CONSENT
(Re: Use of Surname of the Father)
I, ______________________________, of legal age, married, Filipino
Citizen and with residence and postal address at
___________________________________ Philippines, under oath depose and
state that:

1. I am the biological father __________________________________

who was born out of wedlock on __________________________ at
________________________________________________ and her
fact of birth was duly registered at the Office of the Local Civil
Registrar of __________________________, Philippines and
National Statistics Office (NSO);

2. The biological mother of my said child is

_______________________;

3. Being the biological father, I hereby gave my consent and authority

for my child to use my surname ____________________ as her
surname and she shall forever be known as
__________________________________ under the rules and
regulations of Republic Act 9255;

4. I am executing this affidavit to attest to the veracity of all the

foregoing and for all legal intents and purposes it may well serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____

day of __________________ in _______________________________,
Philippines.

___________________________
Affiant

With my conformity:

_________________________________
(Biological Mother)

SUBSCRIBED AND SWORN TO before me this ______________________________

in ___________________________________________________.