REPUBLIC OF THE PHILIPPINES)

CALAO, DUMANGAS, ILOILO )S.S.

AFFIDAVIT TO USE THE SURNAME OF THE

FATHER/ACKNOWLEDGMENT

I, NAME OF THE FATHER of legal age, Filipino, Resident of ADDRESS OF

THE FATHER, Philippines, after having been duly sworn to in accordance with law,
depose and state that:

1. I am the biological father of NAME OF THE CHILD;

2. That the biological mother of the child is NAME OF THE MOTHER;
3. That my child NAME OF THE CHILD was born on BIRTH DATE in PLACE OF
BIRTH;
4. The facts of the birth of my child were duly registered at the Office of the Caloocan
City Civil Registrar.
5. That I NAME OF THE FATHER being the father of NAME OF THE CHILD
hereby acknowledged and recognized him as my child and legal heir;
6. That I am allowing my child NAME OF CHILD to use my surname SURNAME in
his certificate of live birth;
7. That I execute this affidavit to attest to the truth of the above facts in compliance with
the provisions of Republic Act No. 9255.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ day of ____, 2022
in ____________, Philippines.

___________________________
AFFIANT

SUBSCRIBED AND SWORN to before me this _____ day of _______ 2022 in

Iloilo City, Philippines, after affiant exhibiting to me his proof of identification being
_______________ ID with ID No. _____________.

Doc. No.______;
Page No.______;
Book No.______;
Series of 2022