Republic of the Philippines)

Province of Surigao del Norte)

Municipality of Claver) S.S.
x ---------------------------------x

AFFIDAVIT OF ACKNOWLEDGMENT OF PATERNITY AND

CONSENT TO USE SURNAME OF THE FATHER

I, LEOPOLDO GARCIA PINEDA, of legal age, and a resident of Brgy. Tayaga,

Claver, Surigao del Norte, after having been duly sworn to in accordance with law,
hereby depose and state, that:

1. I am the natural or biological father of LEOMID LOYOLA SALUDES who was

born on February 25, 1995 in Alegria, Surigao del Norte;

2. That per Birth Certificate of my child, he is registered in the name of LEOMID

LOYOLA SALUDES;

3. The mother of my child is MILAGROS SALUDES PINEDA and we had been living
together as husband and wife since 1995 ;

4. I likewise hereby give my consent to my child LEOMID LOYOLA SALUDES to

use my last name, and to cause the change of his name in his certificate of live birth from
LEOMID LOYOLA SALUDES to LEOMID SALUDES PINEDA;

5. I am executing this affidavit to change his last name pursuant to RA 9255 and to
apprise all those concerned of the foregoing facts and for whatever other legal purpose it
may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this __day of

_____________________ at Claver, Surigao Del Norte, Philippines.

LEOPOLDO GARCIA PINEDA

Affiant
ID No. __________________________

SUBSCRIBED AND SWORN to before me this ______ day of ____________at

Claver, Surigao Del Norte, Philippines, affiant exhibiting to me his Id his competent
evidence of identity.