REPUBLIC OF THE 

PHILIPPINES)
IBA, ZAMBALES                      ) S.S.
x----------------------------------------x
  

AFFIDAVIT OF DELAYED 
REGISTRATION OF BIRTH

         I, ____________________, of legal age, Filipino, married and a

resident of __________________________, after having been duly
sworn to in accordance with law, depose and state:

1. That I am the applicant for the delayed registration of birth of my

son/daughter ________________________;

2. That he/she was born in ________________ on

_______________________;

3. That I was delayed in registering his/her birth for the reason that
_______________________________________________________.

4. That I am executing this affidavit to attest to the truth and veracity of the
foregoing facts and in compliance with the requirements of the Philippines
Civil Registrar.

         IN WITNESS WHEREOF, I have hereunto set my hand this ____

day of ____________ in Iba, Zambales, Philippines.
          

______________________
Affiant

    SUBCRIBED AND SWORN TO before me this _____ day of

_____________ in Iba, Zambales, Philippines, affiant exhibiting to me
his/her _________________ with No. _________________ issued in
_______________ on ________________ and valid
until _____________________.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2013.