Republic of the Philippines)

Province of _______________……….) S.S.

_________________________..)

AFFIDAVIT OF DELAYED REGISTRATION

I, ______________, of legal age, Filipino, and a resident of ______________________,

after having been duly sworn to in accordance with law, hereby depose and state THAT:

1. I am the legitimate child of spouses ______________ and ___________________,

presently residing at _______________________________;

2. On _____________________ the National Statistics Office (NSO) issued a

certification that I have no record of birth, a copy of Certification is hereto attached.

3. In view hereof, I am requesting the Local Civil Registrar, to reflect in the Book
Registry of Birth the fact of my birth although it is already late;

4. I am executing this affidavit to attest the truthfulness of the foregoing statements and
for the purpose for which this affidavit it may serve;

IN WITNESS WHEREOF, I have hereunto affix my signature this __ day of _________,

at ______________.

____________
Affiant

SUBSCRIBED AND SWORN TO before me this ____ day of _____________, at

________________, affiant exhibiting to me his Resident Certificate No. _______________
Issued on ____________________, Issued at __________________.

WITNESS MY HAND AND SEAL on the date and place above-mentioned.

ATTY. ________________
NOTARY PUBLIC
Until __________
PTR NO. _______________
IPB NO. ________________
Roll No. ______________

Doc. No. _____

Page No. _____
Book No. _______
Series of _______