RA 9255 Form No.

1 Registry Number: _________

(Revised march 2016) Date of Registration:_______

Republic of the Philippines )

) S.S

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

This Deed is made and executed by and between:

1. ______________ , ________________ , __________ , _____ years old, a resident of

(Affiant’s Name) (Citizenship) (Civil Status) (Age)
_______________ , after having been duly sworn in accordance with law, do hereby
(Complete Address)
declare that:
1 . I am seeking to use the surname ___________ in:
My certificate of Live Birth/Report of Birth, pursuant to R.A. No. 9255
and its Revised IRR.
The Certificate of Live Birth/Report of Birth of ____________________
(Complete Name of Child)
Who is my _______________________, pursuant to R.A. 9255.
(relation of Affiant to Child)

2. I/He/She was born on ________________ at ____________________________

(Date of Birth) (City/Municipality) (Province/State)(Country)
3. The birth was recorded under Registry No. ____________on ______________ (if
applicable).
4. The Affidavit of Admission of Paternity of Paternity or the Private Handwritten Instrument was recorded under
Register No. __________ on ___ at the City Civil Registry Office (CCRO)/Philippine Foreign Service Post (PFSP) of
___________________ (if applicable).
5. I am filing this AUSF at the CCRO/PFSP of _______ in accordance with RA No. 9255 and its Revised Implementing
Rules and Regulations
6. I hereby certify that the statements made herein are true and correct to the best of my knowledge and beliefs.
7. In witness hereof, I hereby affix my signature on this ________ day of ___________.

Subscribed and Sworn to before me this ____ day of _ in the City of _______ affiant exhibiting
her _____ issued at ______ on _____________. I certify that I personally examined the affiant
and that he/she voluntarily executed the foregoing affidavit and understood the contents
thereof