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Republic of the Philippines }

Mexico, Pampanga } S.S.

AFFIDAVIT OF FACTS OF BIRTH


I, JINELLA SANTOS DE LEON, of legal age, Filipino citizen, married and residing at
Barangay Suclaban , Mexico, Pampanga, Philippines, after having been duly sworn to in accordance
with law, depose and state:

1. That I am a Registered Midwife with PRC License No. 000000;

2. That on July 26, 2015, I attended the delivery of DANIELA SAMOA SALAZAR,
likewise a resident of Barangay Suclaban, Mexico (P) ;

3. That on the aforesaid date at around 10:00 in the morning in Barangay Suclaban,
Mexico, Pampanga, Daniela Samoa Salazar, gave birth to a healthy baby girl
whom she later on named as “DAINE SALAZAR FABREGAS”;

4. That ARNOLD T. FABREGAS is alleged father of the above-named child. He is


a Filipino citizen and the common law partner of Daniela Samoa Salazar;

5. That the birth of the said child was not immediately reported to and registered
with the Local Civil Registry of Mexico, Pampanga, due to
inadvertence/negligence of the parents; and,

6. That I am executing this Affidavit to attest to the truth of the foregoing facts and
circumstances in support to the delayed/late registration of birth of a certain
DAINE SALAZAR FABREGAS and for other legal intents and purposes.

IN WITNESS WHEREOF, I have hereunto set my hand this 14th day of February 2019 in
Mexico, Pampanga, Philippines.

JINELLA SANTOS DE LEON


Affiant

SUBSCRIBED AND SWORN to before me this February 14, 2019 at Mexico, Pampanga,
Philippines. The Affiant, Jinella S. De Leon, personally appeared and exhibited to me her
Professional Regulatory Commission (PRC) ID with License No. 000000 as competent proof of her
identity.

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Series of 2019.