REPUBLIC OF THE PHILIPPINES)

CITY CEBU ) S.S.

AFFIDAVIT OF DELAYED REGISTRATION OF BIRTH

I, Carlos, 53 years of age, a Filipino citizen and with residence and postal
address at Sitio, after having been duly sworn and oath in accordance with law
hereby voluntarily depose and say:

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

2. That I was born in Negros Occidental on 1965;

3. That my birth was not registered in the Local Civil Registrar for the reason that our
residence, which is a mountain barangay of Murcia, was a far distance from the
Local Civil Registrar Office;

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 Philippines Civil Registrar.

IN WITNESS WHEREOF, I have hereunto set my hand this 28th day

of October 2018 in Cebu City, Philippines.

_________________
Carlos

SUBCRIBED AND SWORN TO before me this 28th day of October 2018 in

Cebu City, Philippines, affiant exhibiting to me his Social Security Identification
No. as his competent proof of identity.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2018.