RA 9255 Form No
RA 9255 Form No
1
(Revised March 2016)
___________________________ ) Registry No. _________
___________________________ ) S.S.
______________________
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________.