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RA9255

Honey U. Cruz, a 32-year-old single Filipino woman from Urdaneta City, Pangasinan, is filing an Affidavit to Use the Surname of the Father to add the surname "Gaco" to the birth certificate of her daughter Renalyn Cruz, who was born on March 9, 2017 in Urdaneta City, Pangasinan. Honey is filing this affidavit at the Local Civil Registry Office of Urdaneta City in accordance with RA 9255 and its revised implementing rules and regulations. She certifies that the statements in the affidavit are true and correct to the best of her knowledge.

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Marc Darwin Ragojos
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373 views1 page

RA9255

Honey U. Cruz, a 32-year-old single Filipino woman from Urdaneta City, Pangasinan, is filing an Affidavit to Use the Surname of the Father to add the surname "Gaco" to the birth certificate of her daughter Renalyn Cruz, who was born on March 9, 2017 in Urdaneta City, Pangasinan. Honey is filing this affidavit at the Local Civil Registry Office of Urdaneta City in accordance with RA 9255 and its revised implementing rules and regulations. She certifies that the statements in the affidavit are true and correct to the best of her knowledge.

Uploaded by

Marc Darwin Ragojos
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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R.A. 9255 Form No.

1
(Revised March 2016)

Registry Number: ________________

Republic of the Philippines )


CITY OF URDANETA ) S.S.

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, _________________________________________,
HONEY U. CRUZ ___________, ___________, ______ years old,
(Affiants Name) (Citizenship) (Civil Status) (Age)
FILIPINO SINGLE 32

a resident of _____________________________________________________________________________
CAMANANG RIVERSIDE, URDANETA CITY, PANGASINAN
(Complete Address)
After having been duly sworn to in accordance with law, do hereby declare that:

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


My Certificate of Live Birth/ Report of Birth, pursuant to R.A.9255 and its Revised IRR.
GACO

The Certificate of Live Birth/ Report of Birth of __________________________________________


RENALYN CRUZ GACO
(Complete Name of Child)
who is my __________________________,
DAUGHTER pursuant to R.A.9255 and its Revised IRR.
(Relationship of the Affiant to the Child)

2. I/ He/ She was born on ___________________


MARCH 09, 2017 at __________________________________________
URDANETA CITY, PANGASINAN, PHILIPPINES
(Date of Birth) (City/ Municipality) (Province/ State) (Country)

3. My/ The birth was recorded under Registry No. _____________ on _________________ (if applicable).
(Registry Number) (Date of Registration)

4. The Affiant of Admission of Paternity or the Private Handwritten Instrument was recorded under
Registry No. _______________ on ____________________ at the Local Civil Registry Office (LCRO)/
(Registry Number) (Date of Registration)

Philippine Foreign Service Post (PFSP) of _______________________________________ (if applicable).


(City/ Municipality) (Province/ State) (Country)
5. I am filing this AUSF at the LCRO/ PFSP of _____________________________________________
URDANETA CITY, PANGASINAN, PHILIPPINES in
(City/ Municipality) (Province/ State) (Country)
in accordance with R.A. 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.
7. In witness whereof, I hereby affix my signature this _______ day of _________________, 20___ at
Urdaneta City, Pangasinan.

___________________________________
HONEY U. CRUZ

(Signature Over Printed Name of Affiant)

SUBSCRIBED AND SWORN to before me this ______ day of __________________ in Urdaneta City,
Pangasinan affiant exhibiting his/ her___________________ issued at _____________________________ on
_______________________. I certify that I personally examined the affiant and that he/ she voluntarily
executed the foregoing affidavit and understood the contents thereof.

________________________________
Notary Public

Doc. No. __________;


Page No. __________;
Book No. __________;
Series of __________

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