PAO FORM No.

2010-10

REPUBLIC OF THE PHILIPPINES)

)Ss.

AFFIDAVIT OF ACKNOWLEDGMENT OF PATERNITY, SUPPORT AND

CONSENT TO USE MY LAST NAME

I, of legal age, and a resident of

, after having been duly sworn to in accordance with

law, hereby depose and state, that:

1. I am the natural or biological father of the minor who was born

outside of wedlock on in City;

2. The mother of my child is _;

3. That as such, I hereby oblige to provide my child financial

support in the amount of P monthly;

4. I likewise hereby give my consent for my child to use my last

 name, and to cause the change of her last name in her certificate
of live birth from to _;

5. I am executing this affidavit to apprise all those concerned of the

foregoing facts and for whatever other legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this day

of , at ,
Philippines.

Affiant

SUBSCRIBED AND SWORN to before me this day

of , at
, Philippines. The identity of the affiant is established by his
Philippine Passport No. _, issued on_ .

NAME OF PUBLIC ATTORNEY

Public
Attorney
(Pursuant
to R.A.
9406)