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Date:_____________

PHILIPPINE STATISTICS AUTHORITY- BACOLOD

To Whom it may concern:

The undersigned authorized _____________________ to claim the PSA birth certificate of


my son ________________________ on my behalf.

The said document will be used for school purposes. Attach is the photo copy of my ID and
my child’s ID.

Thank you very much and God bless!

Respectfully Yours:

____________________
Parent/Requester

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