Republic of the Philippines )

Province of Leyte ) Ss
City of Tacloban ) Registry No._______

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, ____________________________of legal age, _____________, and a resident of

(Affiant’s name) (Citizenship)
____________________________________________, after having been duly sworn to
(Complete address)
in accordance with law, do hereby declare that:

1. I am seeking the change of surname in:

a.) my certification of Live Birth b.) Certificate of Live Birth of

______________________________________ who is my __________________________

(Complete name of child) (Relation of affiant to child)

2. I/He/she was born on _________________________at______________________

(Date of birth) (Municipality)
__________________________, ______________________.
(Province) (Country)
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 R.A 9255.
6. I/The father have/has sought the consent of my/the child as shown by his/her
attached consent. (Applicable only if the child is 18 years old and above.)
7. In support hereof, I submit the attached private handwritten instrument including
the following supporting documents: (Use additional sheets, if necessary.)
a.)_________________________________________________________________

b.)_________________________________________________________________
c.)_________________________________________________________________
8. I am filing this Affidavit at the LCRO of___________________________________
in accordance with R.A 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______________________200__.

___________________________________
Signature over printed name of Affiant

SUBSCRIBED AND SWORN to before me this_____ day of________________ 200__

in the city/municipality of ____________________________, affiant exhibiting to me
his Community Tax Certificate No. _______________________ issued on __________________
at_______________________________.

__________________________________
Administering Officer

Doc. No. ___

Page No. ___
Book No.___
Series of ____
 Republic of the Philippines ]
Province of Leyte ] Ss
City of Tacloban ] Registry No._______

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, Leyte.

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 foregoing facts in
accordance with R.A 9255;

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

____________,200__, _________________________.

___________________________
Affiant

SUBSCRIBED AND SWORN to before me this_____ day of________________ 200__

in the city/municipality of ____________________________, affiant exhibiting to me
his Community Tax Certificate No. _______________________ issued on __________________
at_______________________________.

__________________________________
Administering Officer

Doc. No. ___

Page No. ___
Book No.___
Series of ___