Registry No.

Republic of the Philippines)

Province of Pangasinan….) S.S.
City of Dagupan…………..)

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

That I, BRENDA CERVEZA PREZTOZA, of legal age, single, Filipino citizen, a resident at
Casibong, San Jacinto, Pangasinan, Philippines, after having been duly sworn in accordance
with law, do hereby declare and say:

1. I am seeking to use the surname BAUTISTA in:

a.) my certificate of Live Birth, pursuant to R.A. 9255 and its revised IRR.
b.) X the certificate of Live Birth of AMAINA SKY PRESTOZA BAUTISTA who is my DAUGHTER
pursuant to R.A. No. 9255 and its revised IRR.

2. That she was born on AUGUST 17, 2019 at REGION 1, MEDICAL CENTER ARELLANO ST.
DAGUPAN CITY, PANGASINAN PHILIPPINES.

3. That the 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 Local Civil Registry Office
(LCRO) Philippine Foreign Service Post (PFSP) of Dagupan City, Pangasinan, Philippines.

5. I am filling this AUSF at the LCRO of Dagupan City, Pangasinan in accordance with R.A.
No. 9255 and its revised IRR.

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

IN WITNESS WHEREOF, I have hereunto set my hand this 19th day of AUGUST 2019 at
Dagupan City, Pangasinan.

BRENDA CERVEZA PREZTOZA

Affiant

SUBSCRIBED A SWORN to before me, this day of 19th of AUGUST 2019 at Dagupan City,
Pangasinan.

ATTY. FROILAND JOVER F. FERMILL

NOTARY PUBLIC
UNTIL DECEMBER 31, 2020, DAGUPAN CITY
NOTARIAL COMM. SERIAL NO. SNC-NP-29-2018
Doc. No. ATTORNEY’S ROLL NO. 73725, ADMITTED: JUNE 20, 2019
Page No. IBP NO. ________________, PANGASINAN CHAPTER
Book No. 1 PTR. NO. ________________, DAGUPAN CITY, PANGASINAN
Series of 2019. 2ND FLR. CSI MARKET SQUARE, A.B. FERNANDEZ AVE., DAGUPAN CITY