RA 9255 Form No.

Republic of the Philippines)

_____________________)
Registry No.:___________________

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, ______________________________, of legal age, ______________, and a resident of

(Affiants Name)

(Citizenship)

______________________________________, after having been duly sworn in accordance with

(Complete Address)

law, do hereby declare that:

1. I am the father of _____________________(name of child) ;

2. He/She was born on ____________________ (date of birth) at ____________________
Philippines on _________________________(date of birth)

(place of birth)

3. The birth was recorded under Registry Number ___________ on ___________________.

4. I hereby allow ____________________ (name of child) to use my surname in accordance with RA
9255.
5. In support hereof, I submit the attached private handwritten instrument including the following
supporting documents: (Use additional sheets if necessary.)
a) _________________________________________
b) _________________________________________
c) _________________________________________

6. I am filing this affidavit at the LCRO of ____________City in accordance with RA 9255 and its
Implementing Rules and Regulations.
7 . I hereby certify that the statements made herein are true and correct to the best of my knowledge
and belief.
8.

In truth whereof, I have hereunto affixed my signature this ____ day of _________, 20__.

_______________________________
(Signature over printed name of Affiant)

SUBSCRIBED AND SWORN to before me this _______day of _________, 20__ in the City of
____________________, affiant exhibiting his Community Tax Certificate NO.: __________ issued on
____________________ at _______________________________.

City Civil Registrar

(affix official seal here)

http://legalformsphilippines.com

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