Republic of the Philippines )

Province of Iloilo ) S.S.

Municipality of Guimbal )
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AFFIDAVIT

I, ________________, Filipino Citizen, of legal age, married and a

resident of Barangay__________, Philippines, having been duly sworn in
accordance with law, hereby depose and state:

1. That I am the applicant for the change of surname of my child,

________________to _____________;

2. That he was born on November 25, 2016 at Masbate City;

3. That the fact of his birth was registered last November 28, 2016;

4. That he is the second and youngest child;

5. That at that time, I was not yet married to his father,___________;

6. That his father and I only got married on February 1, 2018 at the Office of
the Municipal Mayor of Mandaon, Masbate;

7. That I am executing this affidavit to declare the truth of the foregoing facts

and for the prompt action on the late registration of my birth.

IN WITNESS WHEREOF, I have hereunto set my hand this 14th day of

August 2023 at Guimbal, Iloilo, Philippines.

_______________________
Affiant

SUBSCRIBED and SWORN to before me this 14th day of August 2023 at

Guimbal, Iloilo, Philippines, Affiant exhibited to me her Philippine Identification
Card with Number 6103-6284-0839-5067 issued by Philippine Statistics Authority
as competent proof of her identity.