Republic of the Philippines )

City of Puerto Princesa )S.S.

AFFIDAVIT OF DELAYED REGISTRATION OF BIRTH

I, ERLINDA M. FRAGATA, of legal age, Filipino, married and with

residence at Bonifacio St., Brgy. Bagong Sikat, Puerto Princesa City, Palawan,
after having been sworn in accordance with law do hereby deposes and
state:

1. That I was born on March 28, 1956 in Calintaan, Occidental Mindoro;

2. That said birth was not registered at the Civil Registrars Office of
Occidental Mendoro due to the negligence and of inadvertence on the
part of my parents and the prevailing condition at the time of my birth;

3. That I will submit this Affidavit of Late Registration to the Office of the
Civil Registrar of Puerto Princesa City, Palawan, the soonest to comply
with requirements to process my Certificate of Live Birth;

4. That I executed this affidavit to attest to the truthfulness of the

foregoing instrument purposely for the registration of my birth
ERLINDA M. FRAGATA at the Civil Registrars Office of Puerto
Princesa City, and for whatever legal purpose the same may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this May 19,

2017, at Puerto Princesa City, Palawan, Philippines.

ERLINDA M. FRAGATA /Affiant

PhilHealth No. 09-201191969-5
SUBSRCIBED AND SWORN to before me this May 19, 2017, at Puerto
Princesa City, Palawan. Affiant exhibited to me her respective identification
document as indicated below her name.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2017.