RA 9255 Form No.

1
(Revised March 2016)
___________________________ ) Registry No. _________
___________________________ ) S.S.

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, _____________________________,________________,____________, _______years
old, a resident of
Affiant’s Name Citizenship Civil Status Age
__________________________after having been duly sworn to in accordance with law, do
hereby declare that:
Complete Address
1. I am seeking to use the surname______________________ in:
a) x my Certificate of Live Birth/Report of Birth, pursuant to R.A. 9255 and its Revised IRR
b) the Certificate of Live Birth/Report of Birth of ___________________________,
(Complete Name of Child)
who is my ________________________ pursuant to R.A. 9255 and its Revised IRR
(Relationship of the Affiant to the child)
2. I/He/She was born on _____________ at ____________ ___________, __________.
(date of birth) (municipality) (province) (country)
3. My/The birth was recorded under Registry No.___________ on ______________ (if
Applicable).
(Registry Number) (Date of Registration)
4. The Affidavit of Admission of Paternity or the Private Handwritten Instrument was recorded
under
Registry No. ___________ on ______________ at the Local Civil Registry Office
(LCRO)/Philippine
(Registry Number) (Date of Registration)
Foreign Service Post (PFSP) of ______________________________, _____________(if
Applicable).
(city/municipality) (province) (country/State)
5. I am filing this AUSF at the LCRO/PFSP of_____________________, __________ in
accordance with
(city/municipality) (province) (country/State)
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.
7. In witness whereof, I hereby affixed my signature this ___day of__________,20___
at________________.
______________________________
(Signature over Printed Name of Affiant)

SUBSCRIBED AND SWORN to before me this ____day of __________,in the

city/municipality of ________________, affiant exhibiting his ____________________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.
____________________________
Signature over Printed Name
of the Administering Officer
Doc. No.________;
Page No.________;
Book No._______;
Series of________.
_________________________)
_________________________)SS
SWORN ATTESTATION
I, _____________________________,_____________ citizen,______________
of legal age, with address at _________________________after being sworn in accordance
with law, do 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________________________________, is fully aware of the consequences of the
use of the surname of his/her father.
In witness whereof, I hereby hereto affixed my signature this day of
________________20____in______________,____________.

______________________
Signature of Mother/Guardian
over Printed Name
SUBSCRIBED AND SWORN to before me this _____day of____________ in the
city/municipality of ___________________________________________, affiant exhibiting
his______________________________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.
_____________________________
Signature over Printed Name
of the Administering Officer
Doc. No.________;
Page No.________;
Book No._______;
Series of________.