REPUBLIC OF THE PHILIPPINES )

___________________ ) S.S.

AFFIDAVIT FOR CHILD’S CHANGE OF NAME

AND DELETION OF FATHER’S NAME

I, ___________________, Filipino, of legal age, single, and presently residing at

___________________, after having been duly sworn to in accordance with law hereby
depose and say that:

1. I am seeking deletion of the recorded surname of my son ___________________

at the records of ___________________;

2. My son was born on ___________________ at ___________________;

3. In the hospital records, my son’s recorded surname is ___________________;

4. However, due to my inadvertence, I have not yet registered the birth of my

child at the Local Civil Registrar;

5. Since the biological father of my son already died last ___________________, a

copy of the Certificate of Death is hereto attached as ANNEX “A” and there is
no record whatsoever of his acknowledgment of paternity over my child, I am
now seeking to use the surname of my son from ___________________;

6. At the time of my child’s birth, I was not legally married to his father;

7. Being the mother of ___________________, I hereby acknowledge and

recognize ___________________as my child and legal heir;

8. I am seeking the correction/change my child’s of name from

___________________ to ___________________to be his name in his Certificate
of Live Birth; and

9. I am executing this affidavit to attest the truth of the foregoing and for
whatever legal purpose and intent this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this

___________________in ___________________.

___________________
Affiant

SUBSCRIBED AND SWORN to before me this ___________________in Cebu

City, Philippines, affiant having exhibited to me competent evidence of identity.

Doc. No. ___;

Page No. ___;
Book No. ___;
Series of 2019.