R.A. No. 9255 Form No.

1
(Revised March 2016)

REPUBLIC OF THE PHILIPPINES }

CITY OF SANTA ROSA, LAGUNA }S.S. Registry No. _______________

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, ELZA PAUNAL, Filipino citizen, single, 7 years old, with residence and postal
address at Gawad Kalinga, Brgy. Pulong Sta. Cruz, City of Santa Rosa, Laguna, after having been
duly sworn in accordance with law, hereby depose and state:

1. I am seeking to use the surname PARADELA in:

a) / My Certificate of Live Birth, pursuant to R.A. No. 9255 and its

Revised IRR.

b) Th The Certificate of Live Birth of _______________________ who is my

____, pursuant to R.A. No. 9255 and its Revised IRR.

2. I/He/She was born on 11 November 2008 at the City of Santa Rosa, Laguna,
Philippines;

3. My/The birth was recorded under Registry No. __________ on ____________.

(If applicable);

4. The Affidavit of Admission of Paternity or the Private Handwritten Instruments was

recorded under Registry No. _________on _________ at the Office of the City
Civil Registrar of City of Santa Rosa, Laguna. (if applicable);

5. I am filing this AUSF at the Office of the City Civil Registrar of the City of Santa
Rosa, Laguna in accordance with R.A. No. 9255 and its Revised 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 WITNESS WHEREOF, I have hereunto set my hands on this 11th day of October,
2016 in the City of Santa Rosa, Laguna.

ELZA PAUNAL
Child

SUBSCRIBED AND SWORN TO before me this 11th day of October, 2016 in City of
Santa Rosa, Laguna, affiant exhibiting to me her School ID No. 108485160141 issued by Tagapo
Elementary School, City of Santa Rosa, Laguna. I certify that I personally examined the affiant
and that he/she voluntarily executed the foregoing affidavit and understood the contents
thereof.

FERNANDO V. BALINADO
Doc. No. ___ Notary Public
Page No. __ Until December 31, 2017
Book No. XXVI IBP No. 1010667/ Nov. 4, 2015
Series of 2016 PTR No. 2739560 / January 08, 2016
Roll No. 18325
MCLE No. 0025673/ January 25, 2016
REPUBLIC OF THE PHILIPPINES }
CITY OF SANTA ROSA, LAGUNA }S.S.

SWORN ATTESTATION

I, GEMMA ESPAÑOLA PAUNAL, of legal age, Filipino citizen, single, 49 years old,
with residence and postal address at Gawad Kalinga, Brgy. Pulong Sta. Cruz, City of Santa Rosa,
Laguna, Philippines, after having been duly sworn in accordance with law, hereby depose and
state that I am the mother/guardian of the affiant in the Affidavit to Use the Surname of the
Father [AUSF]; that my child/ward ELZA PAUNAL is fully aware of the consequence of the
use the surname of his/her father:

IN WITNESS WHEREOF, I have hereunto set my hands on this 11th day of October,
2016 in the City of Santa Rosa, Laguna.

GEMMA ESPAÑOLA PAUNAL

Mother

SUBSCRIBED AND SWORN TO before me this 11th day of October, 2016 in City of
Santa Rosa, Laguna, affiant having exhibited to me her Voter's ID No. 3428-0252B-
L2666GEP20000-0.
F

FERNANDO V. BALINADO
Doc. No.___ Notary Public
Page No. ___ Until December 31, 2017
Book No. XXVI IBP No. 1010667/ Nov. 4, 2015
Series of 2016 PTR No. 2739560 / January 08, 2016
Roll No. 18325
MCLE No. 0025673/ January 25, 2016
R.A. No. 9255 Form No. 1
(Revised March 2016)

REPUBLIC OF THE PHILIPPINES }

CITY OF SANTA ROSA, LAGUNA }S.S. Registry No. _______________

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, JESMILLE PAÑARES, Filipino citizen, single, 13 years old, with residence and
postal address at Blk. 6, Lot 36, Ph4, Brgy. Pooc, City of Santa Rosa, Laguna, after having been
duly sworn in accordance with law, hereby depose and state:

7. I am seeking to use the surname CALVARIO in:

a) / My Certificate of Live Birth, pursuant to R.A. No. 9255 and its

Revised IRR.

c) Th The Certificate of Live Birth of _______________________ who is my

____, pursuant to R.A. No. 9255 and its Revised IRR.

8. I/He/She was born on 6 September 2003 at TOLEDO CEBU CITY

PHILIPPINES;

9. My/The birth was recorded under Registry No. __________ on ____________.

(If applicable);

10. The Affidavit of Admission of Paternity or the Private Handwritten Instruments was
recorded under Registry No. _________on _________ at the Office of the City
Civil Registrar of City of Santa Rosa, Laguna. (if applicable);

11. I am filing this AUSF at the Office of the City Civil Registrar of the City of Santa
Rosa, Laguna in accordance with R.A. No. 9255 and its Revised Implementing Rules
and Regulations;

12. I hereby certify that the statements made herein are true and correct to the best of
my knowledge and belief.

IN WITNESS WHEREOF, I have hereunto set my hands on this 4th day of October,
2016 in the City of Santa Rosa, Laguna.

JESMILLE PAÑARES
Child

SUBSCRIBED AND SWORN TO before me this 4th day of October, 2016 in City of
Santa Rosa, Laguna, affiant exhibiting to me her School ID No. 1195-6809-0037 issued by
Southville IV Elementary School. I certify that I personally examined the affiant and that he/she
voluntarily executed the foregoing affidavit and understood the contents thereof.

FERNANDO V. BALINADO
Doc. No. ___ Notary Public
Page No. ___ Until December 31, 2017
Book No. ___ IBP No. 1010667/ Nov. 4, 2015
Series of 2016 PTR No. 2739560 / January 08, 2016
Roll No. 18325
MCLE No. 0025673/ January 25, 2016
REPUBLIC OF THE PHILIPPINES }
CITY OF SANTA ROSA, LAGUNA }S.S.

SWORN ATTESTATION

I, JOSEPHINE PAÑARES CALVARIO, of legal age, Filipino citizen, married, 32

years old, with residence and postal address at Blk. 6, Lot 36, Ph4, Brgy. Pooc, City of Santa
Rosa, Laguna, Philippines, after having been duly sworn in accordance with law, hereby depose
and state that I am the mother/guardian of the affiant in the Affidavit to Use the Surname of
the Father [AUSF]; that my child/ward JESMILLE PAÑARES is fully aware of the
consequence of the use the surname of his/her father:

IN WITNESS WHEREOF, I have hereunto set my hands on this 4th day of October,
2016 in the City of Santa Rosa, Laguna.

JOSEPHINE PAÑARES CALVARIO

Mother

SUBSCRIBED AND SWORN TO before me this 4th day of October, 2016 in City of
Santa Rosa, Laguna, affiant having exhibited to me her CTC No. 30998090 issued on 07-11-16
at the City of Santa Rosa, Laguna.
F

FERNANDO V. BALINADO
Doc. No.___ Notary Public
Page No. ___ Until December 31, 2017
Book No. ___ IBP No. 1010667/ Nov. 4, 2015
Series of 2016 PTR No. 2739560 / January 08, 2016
Roll No. 18325
MCLE No. 0025673/ January 25, 2016
R.A. No. 9255 Form No. 1
(Revised March 2016)

REPUBLIC OF THE PHILIPPINES }

CITY OF SANTA ROSA, LAGUNA }S.S. Registry No. _______________

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, KARLA MAE CAPATI, Filipino citizen, single, 11 years old, with residence and
postal address at #1220 Brgy. Pooc, City of Santa Rosa, Laguna, after having been duly sworn in
accordance with law, hereby depose and state:

13. I am seeking to use the surname CARAMAY in:

a) / My Certificate of Live Birth, pursuant to R.A. No. 9255 and its

Revised IRR.

d) Th The Certificate of Live Birth of _______________________ who is my

____, pursuant to R.A. No. 9255 and its Revised IRR.

14. I/He/She was born on 9 May 2005 at the City of Santa Rosa, Laguna,
Philippines;

15. My/The birth was recorded under Registry No. __________ on ____________.
(If applicable);

16. The Affidavit of Admission of Paternity or the Private Handwritten Instruments was
recorded under Registry No. _________on _________ at the Office of the City
Civil Registrar of City of Santa Rosa, Laguna. (if applicable);

17. I am filing this AUSF at the Office of the City Civil Registrar of the City of Santa
Rosa, Laguna in accordance with R.A. No. 9255 and its Revised Implementing Rules
and Regulations;

18. I hereby certify that the statements made herein are true and correct to the best of
my knowledge and belief.

IN WITNESS WHEREOF, I have hereunto set my hands on this 27th day of July, 2016
in the City of Santa Rosa, Laguna.

KARLA MAE CAPATI

Child

SUBSCRIBED AND SWORN TO before me this 27th day of July, 2016 in City of Santa
Rosa, Laguna, affiant exhibiting to me her School Year 2016 issued by the City of Santa Rosa,
Laguna. I certify that I personally examined the affiant and that he/she voluntarily executed the
foregoing affidavit and understood the contents thereof.

FERNANDO V. BALINADO
Doc. No. 144 Notary Public
Page No. 30 Until December 31, 2017
Book No. XVIII IBP No. 1010667/ Nov. 4, 2015
Series of 2016 PTR No. 2739560 / January 08, 2016
Roll No. 18325
MCLE No. 0025673/ January 25, 2016
R.A. No. 9255 Form No. 1
(Revised March 2016)

REPUBLIC OF THE PHILIPPINES }

CITY OF SANTA ROSA, LAGUNA }S.S. Registry No. _______________

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, JAY-AR REGONIA, Filipino citizen, single, 16 years old, with residence and postal
address at #1398 Lanka St., Garcia Subd., Brgy. San Antonio, City of Biñan, Laguna, after
having been duly sworn in accordance with law, hereby depose and state:

1. I am seeking to use the surname BELISON in:

a) / My Certificate of Live Birth, pursuant to R.A. No. 9255 and its

Revised IRR.

b) The Certificate of Live Birth of _______________________ who is my

____, pursuant to R.A. No. 9255 and its Revised IRR.

2. I/He/She was born on 18 May 1999 at Brgy. Dita, Santa Rosa, Laguna,
Philippines;

3. My/The birth was recorded under Registry No. 2000-4919 on November 21,
2000. (If applicable);

4. The Affidavit of Admission of Paternity or the Private Handwritten Instruments

was recorded under Registry No. _________on _________ at the Office of the
City Civil Registrar of City of Santa Rosa, Laguna. (if applicable);

5. I am filing this AUSF at the Office of the City Civil Registrar of the City of Santa
Rosa, Laguna in accordance with R.A. No. 9255 and its Revised 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 WITNESS WHEREOF, I have hereunto set my hands on this 23rd day of August,
2016 in the City of Santa Rosa, Laguna.

JAY-AR REGONIA
Child

SUBSCRIBED AND SWORN TO before me this 23rd day of August, 2016 in City of
Santa Rosa, Laguna, affiant exhibiting to me his School Year 2015-2016 issued by Jacobo Z.
Gonzales Memorial National High School, City of Biñan, Laguna. I certify that I personally
examined the affiant and that he/she voluntarily executed the foregoing affidavit and
understood the contents thereof.

FERNANDO V. BALINADO
Doc. No. ___ Notary Public
Page No. ___ Until December 31, 2017
Book No. XX IBP No. 1010667/ Nov. 4, 2015
Series of 2016 PTR No. 2739560 / January 08, 2016
Roll No. 18325
MCLE No. 0025673/ January 25, 2016