RA 9255 Form No.

1
(Revised May 2004)

Republic of the Philippines )

City of Tacloban ) S.S. Registry No.      

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I,       of legal age,       , and resident of

(Affiant’s Name) (Citizenship)

      , after having been duly sworn to in accordance with law, do

Hereby declare that:

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 on       at      
      ,      
3. The birth was recorded under Registry No.       on      

4. The public document was recorded under Registry No.       on      

at the LCRO of       (if applicable).

5. The surname to be changed is from       to      
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 LCRO of       in accordance 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 signature this    day of       20   

Signature Over Printed Name of Affiant

SUBSCRIBED AND SWORN to be before me this    day of       20    ,

in the City of Tacloban, affiant exhibiting his Community Tax Certificate No.      
issued at       on       .

Administering Oath
Doc No.
Page No.
Book No.
Series of 20

Republic of the Philippines )

City of Tacloban ) S.S.

AFFIDAVIT OF THE MOTHER

I,       , of legal age, Filipino and a resident of

      , after having been sworn to an oath in accordance
with law hereby depose and sayeth;

THAT I am the LEGITIMATE mother of       , who

was born last       , Tacloban City.

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;

IN WITNESS WHEREOF, I hereunto affix my signature this    day of      

20    ,       .

___________________
Affiant

SUBSCRIBED AND SWORN to before me this    day of      

20    , Tacloban City.

___________________