RA 9255 Form No.

1
(Devised May 2004)

Republic of the Philippines)
Alaminos City, Pangasinan)ss
Registry No.:___________________

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, ______________________________, of legal age, ______________, and a resident of
(Affiants Name) (Citizenship)
______________________________________, after having been duly sworn in accordance with
(Complete Address)
law, do hereby declare that:

1. I am seeing the use of the surname ______________________________ in:

a) my Certificate of Live Birth/Report of Birth, pursuant to RA No. 9255
b) the Certificate of Live Birth/Report of Birth of ____________________________
(complete name of child)
who is my _________________________, pursuant to RA 9255.
(relation of Affiant to child)
2. I/He/She was born on ____________________ at Alaminos City, Pangasinan, Philippines.
(date of birth)
3. The birth was recorded under Registry Number ___________ on ___________________.
4. The public document was recorded under Registry number ________ on _____________
at the LCRO of ____________________________________ (if applicable).
5. I/The father have/has sought the consent of my/the child by his/her attached consent.
(Applicable only if the child is 18 years old and above. Not applicable if the child is the affiant.)
6. In support hereof, I submit the attached private handwritten instrument including the
following supporting documents: (Use additional sheets if necessary.)
a) _________________________________________
b) _________________________________________
c) _________________________________________
7. I am filing this affidavit at the LCRO of Alaminos City, Pangasinan in accordance with RA
9255 and its Implementing Rules and Regulations.
8. I hereby certify that the statements made herein are true and correct to the best of my
knowledge and belief.
9. In truth whereof, I have hereunto affixed my signature this ____ day of _________, 200__.

_______________________________
(Signature over printed name of Affiant)

SUBSCRIBED AND SWORN to before me this _______day of _________, 200__ in the
City of Alaminos, Pangasinan, affiant exhibiting his Community Tax Certificate NO.: __________
issued on ____________________ at _______________________________.



REYNALDO R. CASTRO
City Civil Registrar

(Affix Official Seal Here)