Republic of the Philippines )

PROVINCE OF XXX )s.s. Registry No._________

AFFIDAVIT FOR LATE REGISTRATION

I, XXXX, of legal age, Filipino, and resident of XXXX, after having been
duly sworn in accordance with law, do hereby depose and state that:

1. I am the same person executing this Instrument;

2. Out of wedlock, CCC was born to me on April 8, 2012 in XXX;

3. I am executing this instrument in support of my application for

the late registration of CCCC in the Local Civil Registrar of XXX;

4. I am executing this Instrument to declare and attest to the

veracity and truthfulness of the foregoing.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 2 nd

day of October, 2017 hereat XXX.

XXXX
Affiant

SIGNED IN THE PRESENCE OF:

_______________________ ________________________

SUBSCRIBED AND SWORN TO before me this 2 nd day of October, 2017

hereat XXX.

Notary Public

Page No. _________

Doc. No. _________
Book No. _________
Series of 2017.