Republic of the Philippines )

PROVINCE OF BOHOL ) S.S.

City of Tagbilaran )
x--------------------------------------------x

AFFIDAVIT TO USE THE SURNAME OF FATHER

I, JOEL C. ARBAS, JR., Filipino citizen, minor, single, and a resident of Poblacio
I, Tagbilaran City, Bohol, Philippines, after having been duly sworn to in accordance
with the law, do hereby depose and state that:

1. I am seeking to use the surname “ARBAS” in my Certificate of Live Birth/Report

of Birth pursuant to R.A. No. 9255 and its revised IRR.

2. I was born on December 26, 2014 at Taboc, Opol, Misamis Oriental, Philippines;

3. The Affidavit of Admission of Paternity or the Private Handwritten Instrument

was recorded under Registry No. __________________ on ___________ at the
Local Civil Registrar’s Office of Tagbilaran City, Bohol, Philippines;

4. I am filing this Affidavit to Use Surname of Father at the Local Civil Registrar’s
Office of Tagbilaran City, Bohol, Philippines in accordance with R.A. No. 9255
and its revised IRR;

5. I am executing this affidavit to attest to the truth of the foregoing facts and for
whatever legal purpose it may serve.

IN WITNESS WHEREOF, I hereunto affixed my signature this

________________________ at Tagbilaran City, Bohol, Philippines.

JOEL C. ARBAS, JR.

Affiant
ID NO.: ____________________

SUBCRIBED AND SWORN to before me this ____________________- at

Tagbilaran City, Bohol, Philippines. Affiant exhibited to me his identification document
as shown above.
Book No. _____;
Series of 2022.