REPUBLIC OF THE PHILIPPINES)

Quezon City, Metro Manila ) S.S.

AFFIDAVIT OF NO RECORD OF BIRTH

I, ________________________, of legal age, single and a resident of

_____________________________, after having been duly sworn to in
accordance with law, hereby depose and state:

1. THAT my date of birth is on ____________ at

___________________;

2. THAT my father is ________________ and my mother is

___________________;

3. THAT on __________________, I went to the Philippine Statistics

Authority (Office of the Civil Registrar General) to inquire and
secure a copy of my record of birth or birth certificate;

4. THAT said Office issued a certification stating among others

that they do not have any record of my birth;

5. THAT, I am executing this Affidavit to attest to the truth of the

foregoing facts and to use the same for whatever legal purpose
it may serve.

Further, Affiant sayeth naught.

IN WITNESS WHEREOF, I hereunto affix my signature this ___

day of _________________at Quezon City, Philippines.

_________________________
Affiant

SUBSCRIBED AND SWORN to before me this ______day of

______________2019 at Quezon City, Affiant exhibiting to me
his _________________________________ issued by ____________________ and will
expire on ___________________.

Notary Public
Doc. No. : _______
Page No. : _______
Book No. : _______
Series of 2019.