Republic of the Philippines)

City of Cebu…………………….)ss.
x------------------/

AFFIDAVIT

I, _________________, of legal age, Filipino, and presently residing at

_____________________________, after having been duly sworn to in accordance with
law, do hereby depose and state: That-

1. I am the natural father of ___________________.

2. I and ___________________, the natural mother of ____________, have not

been married nor are living together as husband and wife.

3. I hereby give consent and shall not oppose any petition that may be filed for
the change of the said child’s surname from ___________ to _________.

4. I likewise voluntarily waive my right to seek custody of ____________ and

freely relinquish the same in favor of____________, the mother of the said child.

5. I shall not interfere with the upbringing or whatever affairs of _____________

and I fully surrender parental authority to ________________, the mother of the said
child.

6. I have not entered into an agreement regarding the financial support for
_____________ nor have I given any financial support to her since _______________.

7. I am purposely executing this affidavit to attest to the truth of the foregoing

facts and for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I hereunto affixed my signature this

__________________ at Cebu City, Philippines.

_________________
Affiant

SUBSCRIBED AND SWORN to before me this ______________ in Cebu City,

Philippines. Affiant exhibited to me his GSIS ID no. _____________ as proof of his
identity.

Doc. no. _______;

Page no. _______;
Book no. _______;
Series of 2016.