AFFIDAVIT-TO-USE-THE-SURNAME-OF-THE-FATHER.docx - REPUBLIC...

REPUBLIC OF THE PHILIPPINES)
CITY OF DAVAO ) SS
Registry Number: 698699
AFFIDAVIT TO USE THE SURNAME OF THE FATHER
I, Levi X. Ackerman , Filipino, Single, 27 years old, a resident of
Unit No. 232, Camella Northpoint, Buhangin, Davao City after
having been duly sworn to in accordance with law, do hereby
declare that:
1. I am seeking to use the surname Ackerman in:
a) my Certificate of Live Birth/Report of Birth,
pursuant to R.A. No. 9255 and its Revised IRR.
b) the Certificate of Live Birth/Report of Birth of
Jennifer Lawrence who is my child, pursuant to R.A. No.
9255 and its Revised IRR.
2. She was born on December 25, 2018 at Davao City,
Philippines.
3. The birth was recorded under Registry No. 6019 on
January 10, 2019.
4. The Affidavit of Admission of Paternity or the Private
Handwritten Instrument was recorded under Registry No.
6099 on January 6, 2019 at the Local Civil Registry Office