RA 9255 Form No.

1(Devised May 2004)

Republic of the Philippines )

Cainta, Rizal ) S.S. AUSF Registry No. ________

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, MONICA JEAN CANTUBA MACABENTA, Filipino, of legal age, and a

resident of Unit 206 Building A, Domus One Cainta, St. John Street, Barangay
San Andres, Municipality of Cainta, Province of Rizal, under oath, do hereby
depose and states, that:

I am seeking for the use of surname in:

a) X my Certificate of Live Birth

b) the Certificate of Live Birth of

I was born on August 31, 1995 at Cainta, Rizal;

The birth was recorded under Registry No. 95-1751 at the LCRO of
Cainta, Rizal.

I am filing this affidavit at the LCRO of Cainta, Rizal.

I hereby certify that the statements made herein were true and correct to
the best of my knowledge and belief.

IN WITNESS WHEREOF, I have hereunto set my hand and respective

signature this 23rd day of November 2023 at Cainta, Rizal.

MONICA JEAN C. MACABENTA

CRN: 0111-4862329-6
Issued by SSS
Affiant

SUBSCRIBED AND SWORN TO before me on the date and at the place

above-written.
Atty. CRISPINO T. PABLO, JR.
Doc. No. 285 ; Notary Public
Commission No. 22-12/Roll No. 49638
Page No. 57 ; Valid until December 31, 2023
Book No. CLIX ; PTR No. 19168757/ Rizal
IBP Life Time No.06270/Rizal
Series of 2023. MCLE Compliance No. VII-0010698