R.A. 9255 Form No.

1
(Revised March 2016)

Registry Number: ________________

Republic of the Philippines )

CITY OF URDANETA ) S.S.

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, _________________________________________,
HONEY U. CRUZ ___________, ___________, ______ years old,
(Affiants Name) (Citizenship) (Civil Status) (Age)
FILIPINO SINGLE 32

a resident of _____________________________________________________________________________
CAMANANG RIVERSIDE, URDANETA CITY, PANGASINAN
(Complete Address)
After having been duly sworn to in accordance with law, do hereby declare that:

1. I am seeking to use the surname _____________________ in:

My Certificate of Live Birth/ Report of Birth, pursuant to R.A.9255 and its Revised IRR.
GACO

The Certificate of Live Birth/ Report of Birth of __________________________________________

RENALYN CRUZ GACO
(Complete Name of Child)
who is my __________________________,
DAUGHTER pursuant to R.A.9255 and its Revised IRR.
(Relationship of the Affiant to the Child)

2. I/ He/ She was born on ___________________

MARCH 09, 2017 at __________________________________________
URDANETA CITY, PANGASINAN, PHILIPPINES
(Date of Birth) (City/ Municipality) (Province/ State) (Country)

3. My/ The birth was recorded under Registry No. _____________ on _________________ (if applicable).
(Registry Number) (Date of Registration)

4. The Affiant of Admission of Paternity or the Private Handwritten Instrument was recorded under
Registry No. _______________ on ____________________ at the Local Civil Registry Office (LCRO)/
(Registry Number) (Date of Registration)

Philippine Foreign Service Post (PFSP) of _______________________________________ (if applicable).

(City/ Municipality) (Province/ State) (Country)
5. I am filing this AUSF at the LCRO/ PFSP of _____________________________________________
URDANETA CITY, PANGASINAN, PHILIPPINES in
(City/ Municipality) (Province/ State) (Country)
in accordance with R.A. 9255 and its Revised Implementing Rules and Regulations.
6. I hereby certify that the statements made herein are true and correct to the best of my knowledge and
belief.
7. In witness whereof, I hereby affix my signature this _______ day of _________________, 20___ at
Urdaneta City, Pangasinan.

___________________________________
HONEY U. CRUZ

(Signature Over Printed Name of Affiant)

SUBSCRIBED AND SWORN to before me this ______ day of __________________ in Urdaneta City,
Pangasinan affiant exhibiting his/ her___________________ issued at _____________________________ on
_______________________. I certify that I personally examined the affiant and that he/ she voluntarily
executed the foregoing affidavit and understood the contents thereof.

________________________________
Notary Public

Doc. No. __________;

Page No. __________;
Book No. __________;
Series of __________