REPUBLIC OF THE PHILIPPINES )

PROVINCE OF TARLAC ) S.S.

MUNICIPALITY OF CAPAS )
x-------------------------------------x

AFFIDAVIT OF DELAYED
REGISTRATION OF BIRTH

I, ANA LUISA PERALTA SURLA, of legal age, Filipino, single and a

resident of Camino St., ODonnell, Capas, Tarlac, after having been duly sworn to
in accordance with law, depose and state:

1. That I am the applicant for the delayed registration of birth of my son GERALD
SURLA REPUBLO;

2. That he was born in Capas, Tarlac on May 22, 2016;

3. That I was delayed in registering the birth of my son for the reason of inadvertence
of the Ospital ng Capas, where I gave birth;

4. That I am executing this affidavit to attest to the truth and veracity of the foregoing
facts and in compliance with the requirements of the Philippine Civil Registrar.

IN WITNESS WHEREOF, I have hereunto set my hand this _____ day

of October, 2016, in Capas, Tarlac, Philippines.

ANA LUISA PERALTA SURLA

Affiant

SUBCRIBED AND SWORN TO before me this _____ day of October, 2016 in

Capas, Tarlac, Philippines, affiant exhibiting to me her
__________________________________________________.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2016.