REPUBLIC OF THE PHILIPPINES)

CITY OF DAVAO ) SS

Registry Number: 668866

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, Manny Y. Ack, Filipino, Married, 35 years old, a resident of House 69
Buhangin, Davao City after having been duly sworn to in accordance with law, do
hereby declare that:

1. I am seeking to use the surname Ack in:

a) my Certificate of Live Birth/Report of Birth, pursuant to R.A.
No. 9255 and its Revised IRR.
b) the Certificate of Live Birth/Report of Birth of Joseph Y. Ogag
who is my child, pursuant to R.A. No. 9255 and its Revised IRR.
2. He was born on December 25, 2018 at Davao City, Philippines.
3. The birth was recorded under Registry No. 6019 on January 1, 2019.
4. The Affidavit of Admission of Paternity or the Private Handwritten
Instrument was recorded under Registry No. 6099 on January 8, 2019 at the
Local Civil Registry Office (LCRO) Davao City, Philippines.
5. I am filing this AUSF at the LCRO of Davao City, Philippines 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.
7. In witness whereof, I hereby affix my signature on this 15th day of
December, 2019 at Davao City, Philippines.
 Manny Y. Ack
Affiant

SUBSCRIBED AND SWORN to before me this 15th day of December in the

city of Davao, affiant exhibiting his SSS. No. 6969. I certify that I personally
examined the affiant and that he/she voluntarily executed the foregoing affidavit
and understood the contents thereof.

Henry Mason
Administrative Officer

Doc. No. _____; EMILIO O. SORIANO

Page No. _____; NOTARY PUBLIC
Book No. _____; Until Dec. 31, 2022
Series of 2019. Serial No. 2021-999-9999
PTR. No. 99999/01-08-21
Davao City Roll of Atty.’s No. 99999

IBP. Lifetime Roll No. 99999