You are on page 1of 1

BI FORM 2014-01-005 Rev 0

This document may be reproduced and is NOT FOR SALE



I, ____________________________________________________________________________,
[Name in Philippine Document]

also known as _______________________________________________________, _____ years of age,

[Name in foreign passport]

male/female, am single/widowed/divorced/annulled/separated/married to _________________________

(underline applicable)

____________________________. I, a citizen of _________________and resident of _______________

____________________________________________ with contact number ______________________,
after being sworn to in accordance with law, hereby declare under oath that:
1. I am a former natural-born Philippine citizen, born on ___________________________________
[DD-MMM-YYYY e.g. 01 JAN 1990]

at ___________________________to _______________________________________________,
[Fathers name]

[as appearing in Philippine document]

_______________________________citizen by birth/election/marriage/naturalization, who was

[Fathers citizenship at the time of petitioners] birth

[at the time of the petitioners birth(underline applicable)]

married/not married to ___________________________________________________________,

[Mothers name]

_____________________________citizen by birth/election/marriage/naturalization;
[Mothers citizenship at the time of petitioners birth]

[at the time of petitioners birth (underline applicable)]

2. I lost my Philippine citizenship when I became a citizen of ________________________________

on _____________________. Presently, I am a holder of a valid ___________________ passport
with number _________________ issued on ___________________ at ____________________;
[DD-MMM-YYYY e.g. 01 JAN 1990]

3. I took my Oath of Allegiance to the Republic of the Philippines on __________________________

[DD-MMM-YYYY e.g. 01 JAN 1990]
at _______________________________;
(If the petitioner is a registered alien with the Bureau of Immigration):
4. I surrender for cancellation my original
Alien Certificate of Registration (ACR)
no. _______________________and/or Immigrant Certificate of Residence/Certificate of Residence
for Temporary Visitors (ICR/CRTV) no. _________________________;
(If with Dependent/s):
5. Included in this petition is/are my unmarried child/ren below eighteen (18) years of age, namely:


(Please use BI Form 2014-01-006 Rev 0 for each dependent to

WHEREFORE, it is prayed that this petition for

Retention and/or Re-acquisition of Philippine
Citizenship under Republic Act No. 9225 be

Date of Birth


be attached to this petition.)


[DD-MMM-YYYY e.g. 01 JAN 1990]

Attach your 2x2 colored

photographwith white
background using
permanent glue in the
photograph box.
The photograph must be taken
within the last three (3) months
from the date of application.


Signature over Printed Name

Date [DD-MMM-YYYY e.g. 01 JAN 1990]

A scanned photograph is not

allowed. A photograph of the
applicant wearing eyewear (i.e.
sunglasses, colored contact lenses,
etc.) or headwear is not acceptable.

I certify under oath that the above statements are true and correct to my own personal knowledge, and based on authentic
documents in my possession.
Applicants Signature over Printed Name

SUBSCRIBED AND SWORN TO before me this ______________ in _______________________, Petitioner personally

appeared and exhibited to me his/her passport with number _____________________ issued on ____________________________
at __________________.
Doc No.: _________
Page No.: ________
Book No.: ________
Series of ________
Page 1 of 1