RA 9048 Form No. 4.1.

(LCRO) 1
(Devised 10 October 2001)

Republic of the Philippines

OFFICE OF THE CITY/MUNICIPAL CIVIL REGISTRAR
Iloilo
Province:____________________
Iloilo
City/Municipality: __________________

Republic of the Philippines )

__________________________ ) SS Petition No. __________________

PETITION FOR CHANGE OF FIRST NAME

Mara Clara Reyes

I, ___________________________________________, Filipino
of legal age, ______________________,
(complete name of petitioner) (nationality/citizenship)
San Martin Street, MYL Subdivision, Barangay Buhang, Jaro, Iloilo City
and a resident of ______________________________________________________________________,
(complete address)
after having been duly sworn to in accordance with law, hereby declare that:

1) I am the petitioner seeking the change of first name in:

a) my Certificate of Live Birth
b) Kheithleyn Reyes
X the Certificate of Live Birth of __________________________________________________
(complete name of owner)
daughter
who is my _____________________________________________________________________.
(relation of owner to the petitioner)
August 19, 1998
2) I/He/She was born on ____________________ at ______________________________________,
Iloilo City
(date of birth) (city/municipality)
Iloilo
_____________________________________________ Philippines
, __________________________________ .
(province) (country)
1998-981
3) The birth was recorded under registry number ___________________________________________ .
5
Kheitleyn
4) The first name to be changed is from _______________________ Katelyn
to _________________________ .

5) The grounds for filing this petition are the following: (Ground selected should be explained/justified
in a separate sheet of paper to be attached to this form.)
a) The first name is extremely difficult to write or pronounce;
b) X Katelyn
I have/He/She has habitually and continuously used _________________ and I/he/she is
publicly known in the community with that first name;
c) The first name is tainted with dishonor;
d) The first name is ridiculous;
e) The first name causes confusion;

6) I submit the following documents to support this petition: (Use additional sheets, if necessary.)
a) ______________________________________________________________________________
NSO Birth Certificate
b) ______________________________________________________________________________
School Records
Community Tax Certificate
c) ______________________________________________________________________________
Barangay Clearance
d) ______________________________________________________________________________
Baptismal Certificate
e) ______________________________________________________________________________

7) I have/He/She has not filed any similar petition and that, to the best of my knowledge, no other
similar petition is pending with any LCRO, Court or Philippine Consulate.

8) I have/He/She has no pending criminal, civil or administrative case in any court or any quasi-judicial
body.
Iloilo City
9) I am filing this petition at the LCRO of ______________________ Iloilo
, ________________________
(city/municipality) (province)
in accordance with R.A. No. 9048 and its implementing rules and regulations.
 2

VERIFICATION

Mara Clara Reyes

I, ___________________________________ , the petitioner, hereby certify that the allegations
herein are true and correct to the best of my knowledge and belief.

Mara Clara Reyes

___________________________________
Signature over printed name of petitioner

24th
SUBSCRIBED AND SWORN to before me this __________ April, 2017
day of ______________________
Iloilo
in the city/municipality of ____________________, petitioner exhibiting his Community Tax Certificate
23326111
No. ________________ Iloilo City
issued at ______________________________ March 11, 2017
on ________________________
.

Atty. Juan Dela Cruz

___________________________
Administering Officer
Doc. No. ________________ NOTARY PUBLIC
Page No. ________________ PTR No. 1234567, Iloilo City, 1/2/17
Book No. ________________ IBP OR No. 654321, Iloilo City, 1/2/17
Attorneys Roll No. 11223
MCLE Compliance Certificate No. IV-0012345,
Iloilo City, 1/2/17