REPUBLIC OF THE PHILIPPINES

CITY/MUNICIPALITY OF ________

PROVINCE OF ________ ) S.S.

AFFIDAVIT OF ADMISSION AND ACKNOWLEDGMENT OF PATERNITY

(Executed pursuant to Article 172, in relation to Article 175, of the Family Code of the Philippines, Republic Act No. 9255, and Administrative Order No. 1, Series of 2004 of the Office of the Civil Registrar General)

I, ________, of legal age, Filipino, single/of marital status ________, holder of ________ bearing No. ________, and presently residing at ________, after having been duly sworn to in accordance with law, do hereby depose and state THAT:

§ 1. I am the biological father of ________ (the “Child”);

§ 2. The Child was born on ________ at ________;

§ 3. The facts of the birth of the Child were duly registered with the Office of the Local Civil Registrar of ________, as evidenced by the Certificate of Live Birth (Registry No. ________), a certified true copy of which is hereto attached and made an integral part hereof;

§ 4. At the time of the conception and birth of the Child, I was not married to the Child’s mother, ________, nor was there any legal impediment for us to marry each other at the time of the Child’s conception, such that the Child is my acknowledged illegitimate child;

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§ 6. Conformably with Republic Act No. 9255 and its Implementing Rules and Regulations, and with my express acknowledgment of paternity, I hereby consent to and authorize the Child to use my surname, ________, in the Child’s Certificate of Live Birth and in all records and documents pertaining to the Child;

§ 7. The mother of the Child, having parental authority over the Child who is a minor, has signified her conformity to the use of my surname by the Child, as shown by her signature appearing below;

§ 8. I understand that this acknowledgment is irrevocable and may be repudiated only on the ground of fraud, mistake, violence, intimidation, undue influence, or falsity, in accordance with law;

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IN WITNESS WHEREOF, I have hereunto set my hand this ________ day of ________, at ________, Philippines.

AFFIANT FURTHER SAYETH NAUGHT.

________
Affiant

WITH MY CONFORMITY (Mother of the Child):

________
Mother / Holder of Parental Authority
ID No. ________

ACKNOWLEDGMENT

REPUBLIC OF THE PHILIPPINES )
CITY/MUNICIPALITY OF ________ ) S.S.

SUBSCRIBED AND SWORN TO before me, a Notary Public for and in the above jurisdiction, this ________ day of ________, at ________, affiant ________ personally appeared before me and was identified by me through the following competent evidence of identity, who is personally known to me or whom I have satisfied myself to be the same person who executed the foregoing Affidavit, and who acknowledged to me that the same is his free and voluntary act and deed:

Competent Evidence of Identity: ________
Issued on / Valid until: ________
Issued at: ________

I further certify that the foregoing instrument, consisting of ________ page(s) including this page, was signed by the affiant and the witnesses in my presence.

WITNESS MY HAND AND SEAL on the date and at the place above written.

NOTARY PUBLIC

Doc. No. ________;
Page No. ________;
Book No. ________;
Series of ________.