Republic of the Philippines

Caloocan City

AFFIDAVIT OF OUT-OF-TOWN REGISTRATION

I, _______________________________ , of legal age, Filipino, Married and resident of

_______________________, after having been sworn to in accordance with law hereby depose and
say:

1. That I was born on ___________________ in __________________, to spouses / parents

__________________________ and __________________________ and was later
baptized in accordance with the rites of the Roman Catholic Church;

2. That my birth was not reported to the Office of the Local Civil Registrar, _________, for
registration due to excusable neglect of my parents, as such, when I verified my records with
the Philippine Statistics Authority (PSA), my name does not appear in the Registry of Births;

3. That I desire to have my birth entered in the Registry of Births of the Office of the Local
Civil Registrar in ______________, as out-of-town registration;

4. That this information is for consideration in attesting my birth date and place in applying
Out-of-Town (delayed) registration of birth
IN WITNESS WHEREOF, I have hereunto set my hand this _______ day
of_______________ 2022 at ________________, Philippines.

___________________________
Affiant

SUBSCRIBED AND SWORN to before me this ______ day of_____________ 2022 at

___________________, Philippines, Affiant presented to me his ______________________
issued on __________________ at San Roque, Northern Samar, as competent proof of her
identity.

Republic of the Philippines

Caloocan City