Republic of the Philippines )

Province of Leyte ) S.S.

City of Tacloban )

A F F I D A VI T
I, ______________________, of legal age, Filipino, and a resident of
_______________________, after having been sworn to in accordance with law,
hereby depose and sayeth:

1. I am the applicant for Delayed Registration of my birth/birth of my child

_____________________________ who was born last
___________________;
2. That the facts of the birth were not promptly reported at the Local Civil
Registrar of _____________________________;
3. That I am executing this Affidavit to attest to the truth of the foregoing
allegations and to prove the facts of said birth.

IN WITNESS WHEREOF, I hereunto affix my signature this

_______________ at Tacloban City.

_______________
Affiant

CORROBORATION
We, ____________________ and ______________________, both of leal
age, Filipino citizens and residents of Tacloban City, after having been duly sworn
to in accordance with law, do hereby jointly depose and say:

That we personally declare the above statements of the foregoing affidavit

to be true and correct to the best of our knowledge and belief, having known her
since birth at ______________________, Philippines.

__________________ _________________
Affiant Affiant

SUBSCRIBED AND SWORN to before me this ___________________ at

Tacloban City.

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