Republic of the Philippines )

PROVINCE OF ISABELA )s.s. Registry No._________

AFFIDAVIT FOR LATE REGISTRATION

I, GIGI M. BARTOLOME, of legal age, Filipino, and a resident of Raniag,

Burgos, Isabela, after having been duly sworn in accordance with law,
do hereby depose and state that:

1. I am the same person executing this Instrument;

2. Out of my cohabitation with MARKFEL E. MANALO, MARK GHIEUZ

BARTOLOME was born on July 7, 2017 at Manuel A. Roxas District
Hospital, San Antonio, Roxas, Isabela;

3. I am executing this instrument in support of my application for the

Late Registration of MARK GHIEUZ BARTOLOME in the Local Civil
Registrar of Roxas, Isabela;

4. I am executing this Instrument to declare and attest to the veracity

and truthfulness of the foregoing.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 26th

day of October, 2017 hereat Roxas, Isabela, Philippines.

GIGI M. BARTOLOME
Affiant

SIGNED IN THE PRESENCE OF:

_______________________ _______________________

SUBSCRIBED AND SWORN TO before me this 26th day of October, 2017

hereat Roxas, Isabela;

Notary Public

Page No. _________

Doc. No. _________
Book No. _________
Series of 2017.