AFFIDAVIT

I, Jason Gaje of legal age, Filipino and a resident of Brgy. Mayana, Guiuan Eastern Samar, after having
been duly sworn to in accordance with law, depose an say:

That I have a Live-in partner and we have now a baby, who was born on June 8, 2017;

That I want that my child shall bear my surname and he shall be named as Matteo Jael Gaje;

That said surname of our child is likewise with the consent of my wife, Mariel Bantilan, although we are
living without the benefits of marriage;

That I am executing this affidavit to asses and show the truth and veracity of my statement above.

In witness where of, I have here and to set my hand this 11 of June 2017 in Guiuan Easter Samar.

JASON GAJE

Applicant

School ID No. 10A-0222359-A

Witness:

1. 2.

Subscribed &, sworn to before me this 11 of June 2017 in Guiuan Eastern Samar

Doc. No.

Page No.

Book No. III

Series of 2017