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RA 9255 Form No

This document is an affidavit form used to legally change a person's surname to that of their father. The affidavit includes spaces for the affiant to provide their personal details like name, citizenship, address and relationship to the child if applying on behalf of a child. It requires the affiant to specify whether they are changing their own birth certificate or their child's and provide details of their birth registration. The affiant must also confirm they are filing this affidavit in accordance with the law to change the surname and certify the statements are true. A section is included for a sworn attestation by the child's mother or guardian confirming the child is aware of the implications of changing their surname.

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EC Mendoza
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318 views2 pages

RA 9255 Form No

This document is an affidavit form used to legally change a person's surname to that of their father. The affidavit includes spaces for the affiant to provide their personal details like name, citizenship, address and relationship to the child if applying on behalf of a child. It requires the affiant to specify whether they are changing their own birth certificate or their child's and provide details of their birth registration. The affiant must also confirm they are filing this affidavit in accordance with the law to change the surname and certify the statements are true. A section is included for a sworn attestation by the child's mother or guardian confirming the child is aware of the implications of changing their surname.

Uploaded by

EC Mendoza
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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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________.

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