REPUBLIC OF THE PHILIPPINES 

)
CITY OF GENERAL SANTOS        ) S.S.
X---------------------------------------------X

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, JANE BERREDO MARCOS, of legal age, single, Filipino, and a resident Sto. Nino Purok 7,
Brgy. Apopong, General Santos City, after having been duly sworn to before competent authority
hereby depose and state:

1. That I am the biological mother of the child KESHA MAE MARCOS ZABALA, born
on December 11, 2016, in Sto. Nino Purok 7, Brgy. Apopong, General Santos city;

2. That I being the mother of my said child ACKNOWLEDGE and RECOGNIZED her as
my child and legal heir;

3. That the biological father of my child is HAMMER REY S. ZABALA;

4. That at the time of the birth of my said child, I was not legally married to his biological
father;

5. That I am allowing my said child to use the surname ZABALA and to be her surname in
her Certificate of Live Birth;

6. That this affidavit is being executed for the purpose of attesting to the truth of the facts
above stated and for whatever legal purpose it my serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature on January 3, 2017 at

General Santos City, Philippines.

CONFORME:

JANE BARREDO MARCOS

Mother / Affiant

Signed in the presence of:

_________________________ _________________________

SUBSCRIBED AND SWORN to before me, this January 3, 2017 in General Santos
City, with affiant exhibiting his Voter ID 6303-0177FE0492HSZ10000, issued on January 14,
2014, issued at General Santos City, Philippines.

Doc. No. 106

Page No. 21
Book No. 1
Series of 2017