RA 9255 Form No.

1
(Revised March 2016)
Registry No. _____________
Republic of the Philippines) Date: ___________________
Province of Kalinga ) S.S By: ____________________
City of Tabuk )

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, _________________________________, _________________, ___________,

Affiants name Citizenship Civil Status

________ years of old, a resident of ____________________________, after having been

age complete address

duly sworn to in accordance with law, do hereby declare that:

1. I am seeking the use of the surname __________________________________ in:

a.) ( ) my certificate of Live Birth/ Report of Birth, pursuant RA No. 9255.

b.) ( ) the certificate of Live Birth/ Report of Birth of ________________________
who is my __________________________, pursuant to RA No. 9255.
Relationship of the affiant to the child

2. I/ He/ She was born on ___________________________ at _____________________

Date of birth municipality
Kalinga, Philippines.

3. My/ The birth was recorded under Registry No. _____________ on _______________
Registry number Date of registration
(if applicable).

4. The public document or the Private Handwritten Instrument was recorded under
Registry No. _______________ on ___________________ at the LCRO/ PFSP of
Registry No Date of Registration

____________________, ___________________, _________________ (if applicable).

Municipality/city

5. I am filing this AUSF at the LCRO/ PFSP of Tabuk City, Kalinga, Philippines in
accordance with RA 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.

7. In witness whereof, I hereby affix my signature on this _____ day of ____________,

2016 at Tabuk City, Kalinga, Philippines.
 ____________________________________
Signature over printed name of affiant

SUBSCRIBED AND SWORN to before me this ______ day of ______________

in the city of Tabuk, Kalinga, affiant exhibiting his/ her ___________________________
issued at ______________________, on _______________________________.

I certify that I personally examined the affiant and that he/ she voluntarily
executed the forgoing affidavit and understood the contents thereof.

Michelle B. Gayagay
Notary till Dec. 31, 2017
Roll No. 63190
IBP OR 1002707; 12- 15- 15
PTR 6317369; 1-4- 16
Tabuk City, Kalinga Province