REPUBLIC OF THE PHILIPPINES )

PROVINCE OF QUEZON ) S.S.

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, MARIVIC ALTAREZ CAO, of legal age, Filipino, married to Marson

Palciso Ribleza, and a resident of Brgy. Peǹafrancia, Gumaca, Quezon after having
been sworn to in accordance with law, do hereby depose and state, that:

1. I am seeking to use the surname RIBLEZA in the Certificate of Live Birth /

Report of Birth of MAXINE CAO, who is my daughter, pursuant to
Republic Act No. 9255 and its Revised Implementing Rules and
Regulations;

2. My daughter, MAXINE CAO was born on January 22, 2006 at Gumaca

District Hospital in Gumaca, Quezon, Philippines;

3. The birth was recorded under Registry No. ______________ on

_____________;

4. The Affidavit of Admission of Paternity or the Private Hand Written was

recorded under the Registry No. _______________ on _________________
at the Municipal Civil Registrar Office of Gumaca, Quezon, Philippines;

5. I am filing this Affidavit to use the Surname of the Father at the Office of
Municipal Civil Registrar Office of Gumaca, Quezon, Philippines in
accordance with RA No. 9255 and its Revised IRR;

6. I executed this Sworn Affidavit to attest the truth of the foregoing statement
and for all legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

______________ at Lucena City, Quezon, Philippines.

MARIVIC ALTAREZ CAO

Affiant

SUBSCRIBED AND SWORN TO before me this ___________________

at __________________, Philippines. Affiant exhibiting to me a government-
issued identification card whose photograph and signature appear thereon as valid
and competent proof of his/her identity.

Doc. No. ____

Page No. ____
Book No. ____
Series of 2023.