(Not applicable for births before 27 February 1931)

AFFIDAVIT OF DELAYED REGISTRATION OF BIRTH

(To be accomplished by the child’s father/mother/guardian)

I, ___________________________________________________________, of legal age, single/married,

First Name Middle Name Last Name

presently residing at _________________________________________________________________________,

Apt./House No., Street, City/Town, Province, Postal Code, Country

after having been duly sworn to in accordance with law, do hereby depose and say that:

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

____________________________________________________________;
Full Name of Child
2. The child was born on __________________________________ at __________________________
Date of Child’s Birth City/Town
________________________________________________________________________________;
Province, Country
3. The child was attended at birth by ____________________________________________________,
who resides at ____________________________________________________________________;
4. The reason for the delay in registering the child’s birth was due to ___________________________
________________________________________________________________________________;
5. I am the ____________________________________ of the child whose birth is being reported.
Relationship to Child
6. I am executing this Affidavit for the purpose of registering the child’s birth at the Philippine
Embassy in Ottawa, Canada.

AFFIANT FURTHER SAYETH NAUGHT.

__________________________________
Affiant’s signature over printed name

SUBSCRIBED AND SWORN to before me on this date of _____________________________ at

_________________________________________________________.

__________________________________
Notary Public/Signing Officer
Doc. No. ___________
Service No. ___________
O. R. No. ___________
Fee Paid ___________