R.

A 9225 form 1 __________________

(Revised March 2016) Registry No. _______

Republic of the Philippines)

City of Kidapawan ) ss
AFFIDAVIT TO USE THE SURNAME OF THE FATHER

That I, NYREL REAGA GENOTA, of legal age, Filipino, single and a residence
of Brgy. Buhay, Makilala, Cotabato, Philippines, after having been duly sworn to in
accordance with law, hereby depose and state that:

1. I am seeking to use the name DAYAL 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 RENIER GENOTA DAYAL Who is my son, pursuant to R.A
No. 9225.

2. He was born on April 11, 2017 at Doong Maternity Clinic, Poblacion Makilala,
Cotabato;

3. His birth was recorded under Registry No. ___________________On____________

4. The Affidavit of Admission of Paternity or the Private Handwritten instrument was

recorded under Registry No. on at the /Philippines
Foreign Service Post (PFSP) of
(if applicable.)

5. I am filing this AUSF at the /PFSP of in accordance with R.A No.

9255 and its revised Implementing Rules and Regulations.

6. I hereby certify that the statements made herein are true and true and correct to the
best of my knowledge and belief.

IN WITNESS WHEREOF, I have here unto affixed my hand this 11th day of April
2017, at City of Kidapawan, Cotabato,, Philippines.

NYREL REAGA GENOTA

( Affiant )
PHILHEALTH ID: 170255811641

SUBSCRIBED AMD SWORN TO BEFORE ME this 17 th day of April 2017,

City of Kidapawan, Cotabato, Philippines