REPUBLIC OF THE PHILIPPINES

PROVINCE OF LA UNION
MUNICIPALITY OF SAN JUAN

)
) S.S
)

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, _____________________________, of legal age, single, and a resident of
___________________________, City of San Fernando, La Union, Philippines, after
having been duly sworn in accordance with law, hereby declare that:
1.
I am seeking the use of the surname DELA CRUZ
Certificate of Live Birth, pursuant to R.A. No. 9255.

in my

2.
I was born on February 14, 1989 at San Fernando City, La Union,
Philippines.
3.
The birth was recorded under Local Civil Registry No. 89-2888 of
the Local Civil Registrar of San Fernando, La Union on February 22, 1989.
4.
My father, JUAN DELA CRUZ executed a public document of
recognition, specifically an Affidavit of Admission of Paternity, a copy of which
is hereby attached.
5.
I am filing this affidavit at the LCRO of San Fernando, La Union in
accordance with RA No. 9255 and its 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 truth whereof, I have hereunto affixed my signature this 24 th day of
August, 2014 at San Juan, La Union, Philippines.

___________________________
Affiant
SUBSCRIBED AND SWORN to before me this 24th day of August, 2014
in San Juan, La Union, the affiant exhibiting to me competent proof of her
identification in the form of her PRC ID No. 12345678 valid until November 5,
2016.

Notary Public

Doc. No.______
Page No. _____
Book No. _____
Series of 2014