AFFIDAVIT OF PATERNITY AND USE OF FATHER’S SURNAME

I, ____________________ of legal age, _______ citizen, and presently residing at

___________________________________________, after having been duly sworn to in
accordance with law, do hereby depose and say:

1. That I am the biological father of ____________________________________;

2. That my child ______________________________ was born on

____________________ at __________________________________________;

3. That the facts of birth of my child were duly registered at the

_______________________________________________________________;

4. That being the father of _____________________, I hereby acknowledge and

recognize ___________________________________ as my child and legal heir;

5. That I am allowing my child _______________________________ to use my surname

to be his/her surname in his Certificate of Live Birth; and

6. That I execute this affidavit to attest to the truth of the above facts in compliance with
the provisions of Republic Act No. 9255 and its Implementing Rules and Regulations.

IN WITNESS WHEREOF, I have hereunto set my hand this __ day of ______ at

____________________.

Affiant
(Signature Over Printed Name)

SUBSCRIBED AND SWORN to before me this ___ day of ______ in the ____________,
affiant exhibiting to me his competent evidence of identity by way of ___________________
issued at ______________________ on ________________.

Doc No. : _____

Page No.: ______
Book No.: ______
Series of _________