Republic of the Philippines)

Province of Cebu )S.S

Municipality of Borbon
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AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, ROQUESA C. SENILONG, Filipino, of legal age, married, and presently residing

at Luog, Borbon, Cebu, after having been duly sworn to in accordance with law, hereby
depose and say that:

1. I am seeking the use of the surname SENILONGin the Certificate of Live Birth
of RONNEL CABALLES SENILONG as written in the COLB who is my
illegitimate child, pursuant to R.A. No. 9255;

2. He was born on February 27, 2009 at Mabalacat District Hospital, Mabalacat,

Pampanga;

3. The child is acknowledged by the father, RONALD SENILONG, through the

execution of an Affidavit of Paternity, at the back of the COLB on a separate
public document;

4. I am filing this AUSF at the Local Civil Registrar’s Office of Borbon, Cebu in
accordance with R.A. No. 9255 and its Revised Implementing Rules and
Regulations;

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

IN WITNESS WHEREOF, I hereby affix my signature on this 25th day of May 2019
at Borbon, Cebu, Philippines.

ROQUESA C. SENILONG
Affiant
VIN No. 2206-0116A-H0886RPC20000-2

SUBSCRIBED AND SWORN to before me this 25th day of May 2019 in Borbon,
Cebu, affiant exhibiting to me her competent evidence of identity as shown above. I certify
that I personally examined the affiant and that she voluntarily executed the foregoing
affidavit and understood the contents thereof.

Doc. No. ______;

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