REPUBLIC OF THE PHILIPPINES)

CITY OF MANILA
)S.S
x---------------------------------------------x

AFFIDAVIT
(of acknowledgment and authority to use surname)
I, AUDIE B. ________, of legal age, Filipino and presently residing at
2648 M. Hizon, Sta. Cruz, City of Manila, after having been duly sworn to in
accordance with law hereby depose and state that :
1.

That I am the legal and biological father of ALYANA ________, who

were born on June 14, 1992, at Jose Fabella Memorial Hospital in
Manila from one Evelyn C. Francisco;

2.

And as the biological father of Alyana _____, I am freely and willing

supporting her;

3.

That I hereby authorizing Alyana _______

to use my
surname/family name as proof of our relationship and paternity,
pursuant to Republic Act No. 9255 also known as An Act Allowing
Illegitimate Children to Use the Surname of their Father;

4.

That I am executing this Affidavit to attest to the veracity of the

foregoing and for any legal purpose it may serve.

IN WITNESS WHEREOF, I hereby set my hand this __ day of April 2012

in the City of Manila.

AUDIE B. _________
Affiant
SUBSCRIBED AND SWORN to before me this ____ day of April 2012 in
the City of Manila.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2012