Republic of the Philippines )

)S.S.

AFFIDAVIT OF TWO DISINTERESTED PERSON

LATE REGISTRATION

We, ________________________and _______________________, both are

Filipino, of legal age, residing at ________________________, after having been duly
sworn to in accordance with law, do hereby depose and say;

1. That we personally know MARIA BACULPO DIAZ, the daughter of ROMAN DIAZ
and GREGORIA BACULPO, being our neighbor and intimate friend of the family
in___________;

2. That he/she was born on December 10, 1975 at Maomawan, Bienunido, Bohol,
and that the said birth was not registered at the Municipal/City Civil Registry
Office of Bienunido, because of inadvertence;

3. That we are not related to the said person either by consanguinity or by affinity
nor do we have any pecuniary interest whatsoever;

4. That we are executing this affidavit to affirm the true facts of the birth record of
MARIA DIAZ who would want to avail of late registration of birth at the Office of
the Civil Registry of Bienunido, Bohol.

IN WITNESS WHEREOF, we hereunto set our hands this ______day of

_________________ at __________________________.

__________________________ __________________________

Affiant Affiant

ID No. : ID No. :
Date Issued : Date Issued :
Place Issued : Place Issued :

Subscribedand sworn to before me this ___th day of ___________________ at

___________________________, Philippines.

Doc. No.________;
Page No.________;
Book No.________;
Series of 2019