REPUBLIC OF THE PHILIPPINES

VALENZUELA CITY


AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I , George N. Bolinao , of Legal Age , Filipino, with Residence and postal address at Blk. 13 Lot 19
Sampaguita St. Almar Subd., Camarin, Caloocan City , under oath, allege:

1. That I am the biological father of Jored Angelo S. Bolinao;
2. That the biological mother of my child is Rachelle Santacera;
3. That my child Jored Angelo was born on June 27, 2014 at Dr. Alonzo Reyes Medical & Lying in
Clinic 26 E Mc Arthur Hi-way Karuhatan Valenzuela City;
4. That the facts of birth of my child Jored Angelo S. Bolinao, were duly registered at the Office
of Civil Registrar Of Valenzuela City;
5. That I, George N. Bolinao , being the father of Jored Angelo S. Bolinao had Aknowledge and
recognized him/her as my child and legal heir/s;
6. That I am allowing my child Jored Angelo S. Bolinao to use my surname , Bolinao , to be
his/her surname ,in his/her Certificate of Live Birth;
7. That my Child shall be known as Jored Angelo Santacera Bolinao;
8. That I execute this Affidavit to attest the truth of the above facts for whatever legal intents
and purposes it mat serve and in compliance with the provision of Republic Act No. 9255.


IN WITNESS WHEREOF, I have hereunto set my hands on this______ day of _______ at
______________________.


With my consent
To use the surname of the Father
Of my Child:

__________________________ __________________________
Mother Father




Subscribed and Sworn to before me on this 8
th
day of July 2014 at Valenzuela City, Affiant
having exhibited to me his SSS IdD with the Number of 03-8938603-4.



Doc. No. _________
Page No. _________
Book No. _________
Series of 2014