REPUBLIC OF THE PHILIPPINES )

PROVINCE OF NORTHERN SAMAR )

MUNICIPALITY OF LAOANG )S.S.

AFFIDAVIT TO USE OF THE SURNAME OF THE FATHER

I, JUAN DELA CRUZ, 48 years old, Filipino citizen and a resident of Sitio
Junction, Barangay Rawis, Laoang, Northern Samar, after having been duly
sworn to in accordance with the law, hereby depose and say:

1. I am the biological father of April.

2. That the biological mother of my child is _____.

3. That my child, ROBERT ACEBUCHE, was born on November

11, 1999 at Brgy. Cabagngan, Laoang, Northern Samar.

4. The facts of birth of my child were duly registered at the Local

Civil Registrar Office, Laoang. N. Samar under Registry Number
2002-1223.

4. That being the father of ROBERT ACEBUCHE, I hereby

acknowledged and recognized ROBERT ACEBUCHE as my child
and legal heir.

5. That I am allowing my child, ROBERT ACEBUCHE, to use my

surname, ACEBUCHE, to be his surname and shall be known as
______.

6. That I am executing this Affidavit to attest to the truth of the

above facts and for whatever legal intents and purpose it may serve
and in compliance with the provisions of Republic Act No. 9255.

IN WITNESS WHEREOF, I hereunto set my hand this 12th day of February

2018 at Laoang, Northern Samar.

REYNALDO G. ACEBUCHE
Affiant
Conforme:

Mother

SUBSCRIBED AND SWORN to before me this 12 th day of February 2018

at Laoang, Northern Samar, Philippines.