Republic of the Philippines )

City of Makati ) S.S.

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

AFFIDAVIT TO USE THE SURNAME OF THE FATHER/ACKNOWLEDGMENT

I, _________________, of legal age, single/married/widow, Filipino citizen, and presently residing at _____________________, after having been duly sworn to in accordance with law, do hereby depose and say:

1. That I am the biological father of _________________.

2. That the biological mother of the child is _________________.

3. That my child _________________ was born on __________ ____, _____ at _________________.

4. That the facts of birth of my child were duly registered at the Office of the __________ Civil Registrar.

5. That I, _________________ being the father of _________________, hereby acknowledged and recognized him as my child and legal heir.

6. That I am allowing my child _________________ to use my surname _________________ to be his surname in his Certificate of Live Birth.

7. That I execute this affidavit to attest to the truth of the above facts in compliance with the provisions of Republic Act No. 9255.

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

___________________________________

Affiant

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 ______;