Republic of the Philippines )

Province of Northern Samar )

Municipality of Gamay )s.c.

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, ANNA DELIA E. LABENIA, 19 years old, single, Filipino and a

resident of Brgy. Lapinig Del Norte, Lapinig, N. Samar, after being sworn to
in accordance with law, hereby depose and say:

1. I am seeking to use the surname DELA CRUZ in the

Certificate of Live Birth of Rhian Labenia Dela Cruz, who is
my daughter, pursuant to Republic Act No. 9255 and its
Revised Implementing Rules and Regulations (IRR).

2. She was born on February 24, 2021, at Oras Doctor’s

Hospital, Brgy. Tawagan, Oras, Eastern Samar.

3. Her father, Joshua Edwin C. Dela Cruz, has

acknowledged her by signing the Affidavit of
Acknowledgment/Admission of Paternity found at the back
of the Certificate of Live Birth.

4. I am filing this AUSF at the LCR of Oras, Eastern Samar in

accordance with R.A. No. 9255 and it Revised IRR.

5. I hereby certify that the statements made herein are true

and correct to the best of my knowledge and belief.

IN WITNESS WHEREOF, I hereunto set my hand this 19th day of

March 2021, in Gamay, Northern Samar.

ANNA DELIA E. LABENIA

SUBSCRIBED AND SWORN to before me this 19th day of March

2021, in Gamay, N. Samar. The affiant exhibited to me her COMEL3EC
Voter’s certification, bearing her signature and photograph, as competent
proof of her identity.