REPUBLIC OF THE PHILIPPINES

OFFICE OF THE CIVIL REGISTRAR OF

MABALACAT PAMPANGA

REPUBLIC OF THE PHILIPPINES)

MABALACAT, PAMPANGA )S.S.
PETITION NO. _________

PETITION FOR CORRECTION OF CLERICAL ERROR

IN THE CERTIFICATE OF LIVE BIRTH

I, TERESITA OLTJENBRUNS, of legal age, married, Filipino and a

resident of 130 Narciso St., Josefa Subd. Angeles City, after having been duly
sworn to in accordance with law, do hereby depose and say:

1. That I am the petitioner seeking corrections of the clerical error in the

Certificate of Live Birth of my son WILLIAM CHARLES
OLTJENBRUNS JR.;

2. That WILLIAM CHARLES OLTJENBRUNS JR. was born on November

10, 1987;

3. His birth was recorded under Local Civil Registry Number 88–00651;

4. The Clerical error to be corrected is :

Item No. Item Description: From To

1 Middlename Fernando Charles

5. The facts/reason for filing of this petition are the following:

TO make all the records consistent in the use of the name and
middlename of WILLIAM CHARLES OLTJENBRUNS, JR.; All the herein
attached documents will attest to the middlename of William Charles
Oltenbruns Jr..

6. I submit the following documents to support this petition, to wit:

a. School record of WILLIAM CHARLES OLTJENBRUNS JR.

b. Consular Report of Birth of WILLIAM CHARLES
OLTJENBRUNS JR.

7. I have not filed any similar petition and that, to the best of my
knowledge, no other similar petition is pending with any LCRC, Court
of the Philippines, Consulate.

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 8. I am filing this petition at the LCRC of Mabalacat, Pampanga in
accordance with R.A. No. 9048 and its implementation rules and
regulations.

TERESITA OLTJENBRUNS
Petitioner

VERIFICATION

I, TERESITA OLTJENBRUNS, the petitioner, hereby certify that the

allegations therein are true and correct to the best of my knowledge and belief.

Petioner

SUBSCRIBED AND SWORN to before me this ______ day of February

2005 at Mabalacat, Pampanga, by herein petitioner exhibiting his/her
_______________________.

Notary Public

Doc. No. ________;

Page No. ________;
Book No. ________;
Series of 2005

ACTION TAKEN BY THE LCR

Granted Denied (Provide the basis for denial)

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_____________________________.

VICTOR TERRY A. MEDINA

Local Civil Registrat
Date:___________________

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ACTION TAKEN BY CRG

Affirmed Impugned
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____________________________.

__________________________
Civil Registrar General
Date:___________________

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Payment of filing fee (Please attach copy of the official receipt)

O.R. No. ________________
Amount Paid ________________
Date Paid _________________