REPUBLIC OF THE PHILIPPINES)

CITY OF ILOILO ) S.S.

x-------------------------------------x

AFFIDAVIT OF MOTHER

I, ___________________________________, of legal age, Filipino, _________ and a resident of _______________________ ____________, after having been duly sworn to in accordance with law, depose and state:

1. That I am the LEGITIMATE mother of RYAN SANTOS who was born last June 25, 2013 in Tacloban City;

2. That I am very much willing to allow my child RYAN SANTOS to use the surname of the father for whatever legal purpose his birth be used;

3. That I am executing this affidavit to attest to the truth of the following facts in accordance with RA 9255.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ day of ___________ 20____ in ____________, _____________, Philippines.

___________________________________

Affiant

Voter's ID No. ______________________

SUBSCRIBED AND SWORN TO before me this _____ day of _________ at ________________ affiant exhibited to his/her competent evidence of identity by way of _________________ issued on __________________ in _______________, Philippines.

Notary Public

Doc. No. ______;

Page No. ______;

Book No. ______;

Series of ______;