REPUBLIC OF THE PHILIPPINES )

PROVINCE OF SAMAR )S.S

CITY OF CALBAYOG )
AFFIDAVAVIT FO DELAYED REGISTRATION OF BITH

I,_____________________________________, Of legal age, Filipino, married and resident of

Brgy._________________________, Sta. Margarita, Samar, Philippines, after have been duly
sworn to in accordance with law, hereby depose and say:
That I am the applicant fro the registration of my bith _____________________who was born on
________________
at Brgy, Napuro, Sta. Margarita, Samar, Philippines

That after the said bith, we were not able to file said Birth Certificate due to some unavoidable
circumtances, said document was not reported for registration to the concerned agency;

That I am executing this affidavit to cause the delayed registration of my

bith_______________________ in the office of the Municipal Civil Registrar of Sta. Margarita,
Samar, Philippines;

IN WITNESS WHREOF, I hereby affixed my signature this________day of MAY______ at

__________________, Philippines.

__________________________
AFFIANT

CTC No:_______________
Issued on:________________
Issued at: ________________________

SUBSCRIBED AND SWORN to before me this __________ day of ____________________

2020 at ______________________, Philippines.