Instruction: Kindly use this template as guide in preparing the Affidavit to be

prepared by person who simulated the birth of a child, other than the petitioner. The
Affidavit will be used as supporting document in filing the petition for administrative
adoption. You may enhance it to include additional information/s that is/are relevant
to the case.

REPUBLIC OF THE PHILIPPINES)

Province of____________________) S.S.
City/Municipality of_____________)
x---------------------------------------x

AFFIDAVIT OF ADMISSION OF SIMULATION OF BIRTH

I, ______________(name of affiant)__________________, Filipino, of legal age, [single]/[married,

and a resident of ___________(address of affiant)____________, after having been duly sworn in
accordance with law, hereby depose and state:

1. That on or about ___________(date) , I left/ gave/ referred to the care and custody of
(name of person/s to whom the child was given)__ a child, __month/year(s) old, since I
personally (or not) knew that she/they has/ve been wanting to have a child of her/their
own; / (otherwise state that the person/persons who left/ gave/ referred the child has been
looking for someone to care of such child);

2. That the biological parent/s of the child is/are ________________________________ who

Is/are resident/s of ____________________________;

other circumstances as to how the child came to the custody of the affiant and his/her
relationship to the child or the petitioner(s) must be stated;

3. That in my ardent desire to ensure that the care for the child will be permanent, I registered
him/her as the child of __(known parents)_____, at the Local Civil Registrar of ___________;

4. That in so doing, (state whether affiant is aware (or not?) that act is against the
law or the act was merely done out of compassion for the child who at that time was in his/her
tender years needing the love and care of a parent);

5. That I am executing this Affidavit to attest to the truth of the foregoing facts and for the
purpose of admitting the fact that I caused the simulation of birth record of ______(name of
child)__________ to make it appear that he/she was born to _(parents)___, who is not his/her
biological mother/parents;

Further Affiant sayeth none.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____th day of ____________
20___ at ____________, Philippines.

________________( Signature)_________________
(Affiant’s Printed Name)

SUBSCRIBED AND SWORN TO BEFORE ME, a notary public in and for

_________(City/Province)____________ this ____th day of ____________ 20___. Affiant personally
came and appeared with _____________(Competent Evidence of Identity)______ issued by the
_________(Government Agency)______ on ___(date)__ at ________(place)_________, bearing his
photograph and signature, known to me as the same person who personally signed the foregoing
instrument before me and avowed under penalty of law to the whole truth of the contents of said
instrument.
Atty ___________________________________________
Notary Public
Doc. No. ____ Commission Serial No. ____________________________
Page No. ____ Notary Public for _______(Province/City)______________
Book No. ____ Until December 31, 20__
Series of 20__ Office: ______________(address)____________________
Roll No. __________
IBP Lifetime Roll No. _________; __/__/__ ;
PTR No. _________ ; __/__/__ ; _(Province)_
MCLE Compliance Cert. No. __________; __/__/__