Académique Documents
Professionnel Documents
Culture Documents
) ) S.S.
Registry No.
of legal age,
(Citizenship)
, and resident of
1. I am seeking the change of surname in: a) my Certificate of Live Birth b) Certificate of Live Birth of who is my 2. I/He/She was born at on , 3. The birth was recorded under o Registry No. n 4. The public document was recorded under o Registry No. n at the (if LCRO of applicable). 5. The surname to be changed t is from o Pursuant to RA 9255. 6. I/The father have/has sought the consent of my child as shown by his/her attached document. (Applicable only if the child is 18 years old and above) 7. In support hereof, I submit the attached private handwritten instrument Supporting documents: (Use additional sheets, if necessary) a) b) c)
8. I am filling Affidavit at the in accordance LCRO of with RA 9255 and its implementing Rules and Regulations. 9. I hereby certify that the statements made herein are true and correct to the best of my knowledge and belief. 10.In truth whereof, I have hereunto affixed my day 2 signature this of 0
SUBSCRIBED AND SWORN to be before me day this of in the City of Tacloban, affiant exhibiting his Community Tax Certificate No. issued o . at n
2 0
Administering Oath
) ) S.S.
THAT I am very much willing to allow , my child to use the surname of the father for whatever legal purpose his birth be used; THAT I am executing this affidavit to attest to the truth of the following facts in accordance with RA 9255;
2 0
day of
___________________ Affiant SUBSCRIBED AND SWORN to before me this , Tacloban City. day of
2 0
___________________