REPUBLIC OF THE PHILIPPINES}

City Of Cebu…………………....}S.S.

AFFIDAVIT TO USE THE SURNAME OF THE FATHER (AUSF)

I, __________, Filipino, of legal age, single, and a __________________, Cebu

City, Philippines, having been duly sworn in accordance with law, do hereby depose
and state: That-

1. I seeking to use the surname _________ in the Certificate of Live Birth/Report

of Birth of ___________ who is my _____________, pursuant to R.A. No. 9255 and its
Revised IRR;

2. He/She was born on _________ at _______________;

3. The birth was recorded under Registry No._______on ___________;

4. The Affidavit of Admission of Paternity or the Private Handwritten

Instrument was recorded under Registry No. ____________ on _________ at the Local
Civil Registry Office (LCRO) of _____________;

5. I am filing this AUSF at the LCRO of Cebu City, Cebu, Philippines in accordance
with R.A. No. 9255 and its Revised Implementing Rules and Regulations;

6. I hereby cert ify that the statements made herein are true and correct to the
best of my knowledge and belief.

IN WITNESS WHEREOF, I have hereunto affix my hand this ____ day of

November 2019 in Cebu City, Philippines.

KENT IAN TALLE

Driver’s License ID NO. H03-11001501

SUBSCRIBED AND SWORN TO before me, a Notary Public for and in the City of
Cebu this 13th day of November 2019, affiant exhibited to me his competent evidence
of identity as shown above expiring on November 14, 2022.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2019.