Republic of the Philippines

Province of Leyte
LOCAL CIVIL REGISTRY OFFICE
MUNICIPALITY OF ABUYOG

Republic of the Philippines )

Municipality of Abuyog Leyte ) s.s. Registry No. 2001-2711

AFFIDAVIT OF CONSENT TO USE

THE SURNAME OF THE FATHER

I, MARISTELA P. NOREGA, of legal age, married to ROLDAN R.

NOREGA, resident of Brgy. Canmarating, Abuyog, Leyte, after having been duly
sworn to in accordance with law, deposes and says:

1. That I am seeking to change the surname in the Certificate of Live

Birth of my son “ROLDELMAR PERAS” to that of “ROLDELMAR PERAS
NOREGA” which is the surname of his father, Roldan R. Norega;

2. That my son was born in Abuyog District Hospital, on February 17,

2001, and his birth was recorded under Registry No. 2001-2711;

3. That at the time of his birth, my husband and I were not yet married.

4. That my husband and I were subsequently married on April 17, 2001

through a civil marriage officiated by the then mayor of Abuyog, Leyte.

5. I hereby file this affidavit at the Office of the Local Civil Registrar of the
Municipality of Abuyog, Leyte in accordance with R.A. No. 925 Implementing
Rules and Regulations;

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

IN WITNESS WHEREOF, I have hereunto set my hand this 16 th of

September 2022 at Abuyog, Leyte, Philippines.

MARISTELA P. NOREGA
(Affiant)

SUBSCRIBED AND SWORN to before me this 16 th of September 2022 at

Abuyog, Leyte, Philippines, affiant exhibiting to me her Philippine Identification
Card No. 3689-0814-0756-9510 issued on June 9, 2021 at Abuyog, Leyte.