AFFIDAVIT TO USE THE SURNAME OF THE FATHER
(Pursuant to Republic Act No. 9255 and its Revised Implementing Rules and Regulations)
REPUBLIC OF THE PHILIPPINES )
________ ) S.S.
I, ________, of legal age, Filipino, single, and a resident of ________, after having been duly sworn to in accordance with law, do hereby depose and state THAT:
1. I am the natural mother of ________ (hereinafter, the "Child"), who was born on ________ in ________, and whose birth is registered under Registry No. ________ with the Office of the Local Civil Registrar of ________;
2. The Child was born out of wedlock, the undersigned and the Child's father not having been married to each other at the time of the Child's birth nor at any time thereafter, and there exists no legal impediment to the use by the Child of the surname of the father;
3. ________, the biological father of the Child, has expressly and voluntarily recognized and acknowledged his paternity over the Child by means of an Affidavit of Acknowledgment/Admission of Paternity, which was recorded under Registry No. ________ on ________ with the Office of the Local Civil Registrar of ________;
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5. As the mother exercising parental authority over the Child, who is below eighteen (18) years of age, and after careful consideration of the welfare and best interest of the Child, I have freely and voluntarily decided, given my full and informed consent, and do hereby allow and authorize the Child to use the surname of the father, namely, ________;
6. I respectfully request that the surname of the father, ________, be entered and reflected in the Certificate of Live Birth of the Child, and that the appropriate annotation be made in accordance with law;
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8. I am executing this Affidavit to attest to the truth of all the foregoing statements, to give my consent for the use by the Child of the father's surname, and for whatever legal purpose this instrument may serve.
IN WITNESS WHEREOF, I have hereunto set my hand this ________ day of ________ at ________, Philippines.
________
Affiant (Mother)
SUBSCRIBED AND SWORN TO before me this ________ day of ________ at ________, Philippines, affiant ________ having personally appeared before me and exhibited to me their competent evidence of identity consisting of ________, valid until ________, and who is personally known to me or duly identified by me to be the same person who executed and voluntarily signed the foregoing instrument, and acknowledged to me that the same is their free and voluntary act and deed.
WITNESS MY HAND AND SEAL on the date and at the place above written.
________
Notary Public
Doc. No.: ________
Page No.: ________
Book No.: ________
Series of ________.