Republic of the Philippines )

City of ) S.S.

AFFIDAVIT FOR DELAYED REGISTRATION OF BIRTH

I, ______________, of legal age, single, Filipino, and a resident of _________________

Philippines, after having been duly sworn to in accordance with law, do hereby depose and say:
1. That I am the applicant for the delayed registration of my birth;

2. That I was born on __________________ at ____________________;

3. That the person who attended my birth was ________________________, a traditional

birth attendant known in our place;

4. That the reason for the delay in registering my birth was due to
______________________;

5. That I am executing this affidavit to attest to the truthfulness of the foregoing statements
and for all legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

___________________ at _______________.

Affiant

SUBSCRIBED AND SWORN to before me this ______________, in _____________,

Philippines, Affiant personally appearing and exhibiting to me his ___________________ as
his competent proof of identity.

Doc No._____;
Page No. ____;
Book No._____;
Series of 2019.