Republic of the Philippines )

Province of Occidental Mindoro ) S.S.

Municipality of Mamburao )

AFFIDAVIT FOR OUT OF TOWN REGISTRATION OF BIRTH

I, MEDIA D. CAJAYON, of legal age, Filipino, married, presently residing at

Brgy. Balansay, Mamburao, Occidental Mindoro, after being duly sworn to in
accordance with law, hereby depose and say:

1. That I am the applicant for the delayed registration of my birth;

2. That I was born on April 15, 1953 in Calapan, Oriental Mindoro from late
spouses Domingo Dulagdan Datiles and Magdalena Dayag Caccam;

3. That I have no knowledge on who attended the delivery of my birth;

4. That my birth was not registered at the Office of the Municipal Civil Registrar of
Calapan, Oriental Mindoro due to my parents’ negligence;

5. That this affidavit is executed to attest to the fact surrounding my birth and to
support my application for delayed registration of birth pursuant to Rule 20 of
Administrative Order No. I, series of 1993.

IN WITNESS WHEREOF, I have set my hand this 27th day of September, 2018
at Mamburao, Occidental Mindoro.

MEDIA D. CAJAYON
Affiant
Senior Citizen ID 001100771-11
Issued by OSCA - Mamburao

ATTESTATION

WE, DOMINGO I. VELARDE and JOSUE P. RINONOS, both of legal ages,

Filipinos and presently residing at Mamburao, Occidental Mindoro, under oath, do
hereby affirm and hereby confirm that foregoing statements are true and correct.

We, further state that we personally know affiant and the person subject for
delayed registration of birth.

DOMINGO I. VELARDE JOSUE P. RINONOS

Affiant Affiant
Senior Citizen ID Senior Citizen ID
No. 0010434-10 No. 000328-06
Issued by OSCA - Mamburao Issued by OSCA - Mamburao

SUBSCRIBED AND SWORN TO BEFORE ME this 27th day of September, 2018

at Mamburao, Occidental Mindoro, and affiants exhibited to me their valid
identification card indicated below their names.