Republic of the Philippines)

Province of Cebu )S.S.

AFFIDAVIT FOR DELAYED REGISTRATION OF BIRTH

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

2. That I was b
3. deceased;
4. That the reason for the delay in registering my birth is due to the inadvertence of
my parents;
5. That a copy of my birth certificate is needed for the purpose of late registration
and to have a record in the Philippine Statistics Office.
6. That I execute this affidavit to attest to the truth of foregoing facts.

SUBSCRIBED AND SWORN to C1173FCD10000-5

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