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, PATRICIA NICOLE C. BUYCO, Filipino, of legal age, and a resident of Narra

Street, Falcon Ville, Midtown Village, Barangay San Andres, Cainta, Rizal, under oath,
do hereby depose and states, that:

I am seeking for the use of surname in:

a) my Certificate of Live Birth

b) x the Certificate of Live Birth of

PATRICK ADRIEL B. DE ROQUE who is my son;

He was born on April 28, 2018 in Cainta, Rizal;

The birth was recorded under Registry No. 2018-578 at the LCRO of Cainta,
Rizal. (if applicable)

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 29th day of February 2024 at Cainta, Rizal.

_________________________
PATRICIA NICOLE C. BUYCO
ID No. 01-026414242-9
Issued by PhilHealth
Affiant

SUBSCRIBED AND SWORN TO before me on the date and at the place above-
written.
Atty. CRISPINO T. PABLO, JR.
Doc. No. ; Notary Public
Page No. ; Commission No. 24-12/Roll No. 49638
Valid until December 31, 2025
Book No. ; PTR No. 21047215/January 2, 2024/Rizal
IBP Life Time No. 06272/Rizal
Series of 2024. MCLE Compliance No. VII-0010698

Republic of the Philippines)

Cainta, Rizal ) SS.
 AFFIDAVIT OF PATERNITY

I, JERIC SABANAL DE ROQUE, Filipino, of legal age, and a resident of No. 6

Don Pepe Street, Matalahib, Quezon City, under oath, do hereby depose and state,
that:

I begot a child who was born on April 28, 2018 in Cainta, Rizal, where the said
child was named as PATRICK ADRIEL B. DE ROQUE;

I have no doubt that I am the biological father of PATRICK ADRIEL B. DE

ROQUE;

This affidavit is being executed to attest to the veracity of the foregoing statement
in order to establish the fact and acknowledge that I am the biological father of
PATRICK ADRIEL B. DE ROQUE, for purposes not contrary to law, morals, good
custom and public policy.

IN WITNESS WHEREOF, we have hereunto set our hands this 29 th day of

February 2024 at Cainta, Rizal.

_________________________
JERIC SABANAL DE ROQUE
Driver’s License No. N02-19-058700
Issued by Land Transportation Office
Valid until November 29, 2024
Affiant

SUBSCRIBED AND SWORN TO before me on the date and at the place above-
written.

Doc. No. ;
Page No. ;
Book No. ;
Series of 2024.