NUMBER

CASH DEPOSIT

DENOT\4lNATlON NO OF PIECES AMOUNT

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SAVINGS
! Peso ! UsDotlar E otherCurrency

s73-7-5730039s-7 RAtlcTAY 0llL4i20?a .11:38:19 Ol{-I TOTAL CASH DEPOSIT

0070 528 '3s075 PHP 59,'051 . 88

69. 064 . 88 BANI(BRANCH CHECK NUMBER AMOUNT

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THIS IS YOUR RECEIPT WHEN MACHINE VALIDATED

TOTAL CHECK DEPOSIT I

rrangay) (Ciiy/}il un icipality) (Povinc) (Country)

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CERTIFICATIoN oFATTENDANTATBTRTH (pnvdd.n. Nur. Miditb,Tradiiood BnhAtberdluHld Eb.l
I h€Eby @diry lhat I attsnded th€ birth of E cfiild who was bom attve A HI anlpn m lhe dab of tilh specified above

Sighahrre INT Addross

Name in Print

nue q Pcition Date

CERNHO{TrcN OF INFORMANT
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tnat all infomation supplhj aro Ere and
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krwl€dgs and belbf.

Name ln Print IOilA L V LE€I

Tite or position ArEeltteetlra lLd. II
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FILLED{'PAT THE OFFICEOF THE CIVILREGISTRAR

9 1r 13

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