Republic of the Philippines )

Labo, Camarines Norte )SS

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I JOCELINE GAMBAN MANATA _ FILIPINO __ , ___SINGLE_______,

(Affiant’s name) (Citizenship) (Civil Status)

___40_years old, a resident of P-4 MALAYA LABO CAMARINES, NORTE , after

(age) (Complete Address)
having been duly sworn to in accordance with law, do hereby declare that:

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

a) [] My Certificate of Live Birth/Report of Birth, pursuant to R.A. No.9255 and its Revised IRR.
b) [ X] the Certificate of Live Birth/ Report of NICOLE MANATA
(Complete Name of child)
who is my _ DAUGHTER __ _____
(Relation of the Affiant to child)

2. I/He/ She was born on FEBRUARY 16, 2019____________ at LABO_____________

(Date of Birth) (CITY/Municipality)

_CAMARINES NORTE_____________, _ PHILIPPINES________________________ __

(Province) (Country)

3. My/ the birth was recorded under Registry No. ____________on _____________ _(if applicable).

4. The Affidavit of Admission of Paternity or the Private Handwritten Instrument was recorded under
Registry No. _________________ on _____________________ at the Local Civil
(Registry Number) (Date of Registration)
Registry Office (LCRO)/ Philippine Foreign Service Post (PFSP) of
(City/Municipality)
________________________ in accordance
(Province) (Country)
5. I am filling this affidavit at the LCRO/PFSP of LABO _____ ___
(City/Municipality)

CAMARINES NORTE_____________ , _ PHILIPPINES____________ in accordance with

(Province (Country)
R.A. No. 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 on this 18TH day of FEBRUARY , 2019
at LABO CAMARINES NORTE .

_______________________________
Signature over printed name of Affiant

SUBSCRIBED AND SWORN to before me this 18TH day of __FEBRUARY __

20_19_in the city/municipality of _LABO, CAMARINES, NORTE_________________, affiant exhibiting
her Community Tax No. 10341911_ issued at ______LABO___________________________ on FEBRUARY
16, 2019 . I certify that I personally examined the affiant and that he/she voluntarily executed the
foregoing affidavit and understood the contents thereof.

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