R.A No. 9255 No.

1
(REVISED MARCH 2016)
Registry Number: ____________
Republic of the Philippines )
Province of Davao del Norte ) S.S
City of Panabo )

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

MAE ANN MERCOLITA GUMBA, Filipino, single, 26 years old, and a resident of Purok 2, San
Vicente, Panabo City, Davao del Norte, Philippines, after having been duly sworn to in
accordance with law do hereby declare that:

1. I am seeking to use the Surname GAMAO in:

a) My Certificate of Live Birth/Report of Birth pursuant R.A No. 9255.

b) The Certificate of Live Birth/Report of Birth of DENIELL SHANE GUMBA GAMAO

(Complete Name of Child)
who is my DAUGHTER pursuant to R.A No. 9255.
(Relationship of the Affiant to the Child)

2. She was born on September 17, 2012 at Panabo City, Davao del Norte, Philippines.
(Date of Birth) (Municipality) (Province) (Country)

3. My/The Birth was recorded under Registry No. _______ on ___________________ (if applicable).
(Reg. No.) (Date of Registration)

4. The Public Document or the Private Handwritten instruments was recorded under Registry

No. ______ on _________________________ at the Local Civil Registry Office (LCRO)/

(Reg. no.) (Date of Registration)
Philippine Foreign Service Post (PFSP) of _____________________________________ (if applicable).
(Municipality) (Province) (Country)

5. I am filing this AUSF at the LCRO/PFSP of Panabo City, Davao del Norte, Philippines.
(Municipality) (Province) (Country)
in accordance with 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.

In Witness Whereof, I hereby affix my signature on this 22nd day of May 2018 at Panabo
City, Davao del Norte, Philippines.

MAE ANN MERCOLITA GUMBA

Affiant

Subsribed and Sworn to before me this 22nd day of May 2018 in the City of Panabo,
Davao del Norte, Philippines, Affiant exhibiting her _______________________ issued at
_____________________ on ____________________ I certify that I personally examined the affiant
and that he/she voluntarily executed the foregoing and understood the contents thereof.
 SWORN ATTESTATION

________________________________________, Filipino, Single/Married, of legal age with address at

Affiant’s Name (Name of Mother/Guardian) Citizenship Civil Status

after being sworn in accordance with law,

_____________________________________________________________
do hereby depose and state that I am the mother/guardian of the affiant in the AUSF. That

my Child/Ward _____________________________________, is fully aware of the consequences

Name of Child
of the use of the surname of his/her father.

In Witness Whereof, I hereby hereunto affixed my signature this _________ day

of ___________________, 20______, in __________________________, Philippines.

______________________________________
Signature of the Mother/Guardian
Over Printed Name

SUBSCRIBED AND SWORN to before me this ______ day of __________________ in the City /

Municipality of _________________ affiant exhibiting his/her _____________________ issued at

_____________________ on ____________________ I certify that I personally examined the affiant

and that he/she voluntarily executed the foregoing and understood the contents thereof.

________________________________
Administering Officer

Doc. No. __________;

Page No. _________;
Book No. _________;
Series of __________.